I 



i LIBRARY OF CONGRESS. 1 



€l)ap. 1\C 



I UXITED STATES OF AMERICA. | 



t 



NATURAL HISTORY, ^ y^^^' 
PATHOLOGY, AND TREATMENT 



EPIDEMIC FEVER, 



AT PRESENT PREVAILING IN 



EDINBURGH AND OTHER TOWNS: 



JOHN ROSE OORMACK, M.D. Edin., F.R.S.E, 

FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH, PHYSICIAN TO THE ROYAL 
INFIRMARY, AND LATE PHYSICIAN TO THE NEW FEVER HOSPITAL, ETC. 



I know that the truth is in the facts, and not in the 
mind which observes them."— Rousseau. 



LONDON: JOHN CHURCHILL. 

EDINBURGH : MACLACHLAN, STEWART & CO. DUBLIN : FANNIN & CO. 
PARIS : FORTIN, MASSON, & Cie. 
1843. 




BALFOUR AND JACK, PRINTERS, EDINBURGH. 



TO 

JOHN ABERCROMBIE, M.D. Edin. & Oxon. 

TICE-PRESIDENT OF THE ROYAL SOCIETY OF EDINBURGH, 
PHYSICIAN TO THE QUEEN, 
&C. &C. &C. 

IS RESPECTFULLY DEDICATED 
IN SINCERE TESTIMONY OF ADMIRATION OF HIM 



AS A MAN AND A PHYSICIAN, 
BY 



THE AUTHOR. 



PREFACE. 



Circumstances, which it is not necessary to explain, 
render it proper to delay the publication of the Appendix. 
It will probably not appear till the close of the epidemic. 

The author cannot allow this Memoir to go forth to the 
world, without publicly and heartily thanking his accom- 
plished friends Dr Heude and Mr. J. W. Reid for the 
efficient assistance which they rendered to him when 
Physician to the New Fever Hospital. 

131 Princes Street, 
Dec. 20, 1843. 



CONTENTS. 



Page. 

INTRODUCTION, 1 

CHAPTER I. — Ordinary or Moderately Congestive Form of the 

Disease, . . . . .3 

CHAPTER II. — Highly Congestive Form of the Disease, . 23 
CHAPTER III.— Pathology of the Disease, . . .84 

CHAPTER IV.— Sequels of the Disease, ... 99 
CHAPTER v.— Treatment of the Disease, . . .149 

CHAPTER VI.—Statistics of the Cases, . . .171 



INTRODUCTION. 



Immediately, on commencing the duties of Physician to the New 
Fever Hospital, I began to report minutely, almost every case 
committed to my charge ; and from that time, till now, have 
rigorously followed the same plan, daily devoting a large portion 
of time, to observing and recording the features of the pre- 
vailing epidemic, both, when interfered with by medicines, and 
when allowed to run its natural course. The leisure of autumn 
being now past, and other professional occupations rendering it 
imperative upon me, to devote much less time than heretofore, to 
Hospital studies, I venture to publish these observations now ; 
fearing, that by delay, I would not amass much more informa- 
tion, and be only able to accumulate imperfect cases. It is 
hoped, however, that the present notes will not be considered 
unseasonable or premature, as in the practice of the large Hos- 
pital, I have already simultaneously watched and contrasted 
with each other, manifold instances of every variety of the 
disease. 

The main object, in what follows, is to present a faithful ac- 
count of the Natural History and Pathology of the prevailing 
epidemic, along with such details of the Treatment followed, as 
appear to be of practical importance. Every fact stated, is 
put forth, almost in the very words in which it was noted down 
at the moment of observation, — a practice, which ought to be 
considered imperative on all, who venture to lay the result of 
their experience before the profession. It cannot be denied, that 
great hindrance has accrued to the improvement of the Science 
of Medicine, from physicians describing the phenomena of disease, 
and the supposed effects of remedies, from general impressions 
remaining in their minds, after the lapse of hours, days, weeks, 

B 



2 



INTRODUCTION. 



or even longer intervals, — in place of founding their statements 
upon an analysis of facts committed to paper, at the very time 
that they were being observed, at the bedside of the living pa- 
tient, or at the dissection of the dead. Neglect of this somewhat 
irksome, but only safe system of recording Medical experience, 
has proved one of the most fruitful sources of discrepancy among 
us, regarding the Natural History of diseases, and the selection 
of therapeutic agents for their treatment. It is in consequence 
of such laxity, as often as from dishonesty, that facts are changed, 
in order to harmonize with theories. " When the mind," says 
Bacon, " is once pleased with certain things, it draws all others 
to consent and go along with them; and though the power and 
number of instances that make for the contrary are greater, yet, 
it either attends not to them, or despises them ; or else, removes 
and rejects by a distinction, with a strong and pernicious preju- 
dice, to maintain the authority of its first choice inviolate." 

It is proposed, in the following paper, first, to describe the 
disease in its ordinary form, drawing the description from cases, 
little, if at all, influenced by therapeutic agents. The severer 
and more unusual varieties of the fever will then be considered, 
by which we will be introduced to important details illustrating 
the next topic — its Pathology. The memoir will also embrace 
statistical details, and practical considerations. 



ORDINARY OR MODERATELY CONGESTIVE FORM, 



CHAPTER L 

ORDINARY, OR MODERATELY CONGESTIVE FORM OF THE DISEASE. 

In ordinary cases, the countenance of the patient has a peculiar 
appearance, which we may designate bronzed, for want of a better 
term. Though no words can accurately convey what is thus at- 
tempted to be described, the appearance itself is very characte- 
ristic, and has never failed to arrest and interest the medical 
visitors to the hospital, to whom it has been pointed out. 

The symptoms of invasion are in all cases remarkably similar, 
both as to their nature, and order of occurrence. 

The patient is first seized with coldness, rigors, headache, pain 
in the back, and more or less prostration of strength ; but the 
latter symptom, it must be remarked, is often not at all urgent, 
many walking long distances from the country to the hospital, 
especially during the first days of the disease ; and a still greater 
number of the destitute town patients lounge about the streets 
after their seizure, and come in to us on their legs. 

After a period, varying from less than half an hour to seve- 
ral hours, the cold fit terminates, when the severity of the 
headache greatly increases, and a dry burning heat comes over 
the whole body, accompanied by much thirst and general un- 
easiness. 

The hot stage is succeeded by a sweat, usually very profuse, 
continuing for a number of hours, and seldom attended or fol- 
lowed by any reHef to the headache or other pains. 

Sometimes, though rarely, there is no sweating for two or three 
days after the seizure. Occasionally also, there is no well-marked 
hot stage between the cold and the sweating fits; and in at least 
a few cases, the sweat breaks out on the face and upper part of 
the body, whilst the patient is yet in his initiatory rigors. 

It is proper to remark, that during the whole course of the 
disorder, the perspiration has a characteristic disagreeable smell, 



4 



ORDINARY OR MODERATELY CONGESTIVE FORM. 



and is decidedly acid, as is proved by its reddening litmus paper, 
and that sometimes with intensity. 

During the three stages of the initiatory paroxysm, the pulse 
is rapid, being sometimes as high as 150, seldom below 90, and 
commonly ranging between 90 and 120. During the rigors, in 
several cases, I have found it very wiry and tremulous; in the hot 
stage, it is often hard, and not very easily compressed; at the 
sweating period, it becomes fuller and softer, and does not exhi- 
bit that deficiency in strength, shown after, and during the per- 
spirations of a more advanced period of the fever. 

For the first 48 hours, the tongue commonly continues moist, 
exhibiting at the same time a white or brownish yellow fur, ex- 
cepting at the point, where there is usually a clear space, extend- 
ing over a space, often, (as in typhm ahdominalis^) shaped like a 
triangle, the extremity of the tongue forming the base. After- 
wards, the tongue becomes dry, and longitudinally streaked on 
the centre with brown, in which state it continues till the ap- 
proach or arrival of the crisis, at from the third to the ninth, 
but in the majority of cases, on the fifth day. 

During the first four days, some of the patients have occasional 
short rigors; but most commonly, they are in a state of dry ardent 
fever, with occasional sweatings. These sweatings occur, or at 
all events, commence in most cases, between two and nine a.m. ; 
but to this rule, there are many exceptions. In a considerable 
proportion, even of the ordinary and mild cases, nausea and 
vomiting usher in and attend the sufferings of the first days. 
Pain at the scrobiculus cordis generally accompanies these symp- 
toms; not unfrequently, it is present without them. A symptom 
which uniformly occurs during the first four days, is severe mus- 
cular and articular pain. General uneasiness, or pain in the ab- 
domen, (but particularly above the pubes, and over the liver and 
spleen, when pressure is made on these regions,) are very com- 
monly, but by no means uniformly met with. 

So long as the patients suffer much from the symptoms now 
described, they sleep badly, and frequently not at all, unless 
opiates are administered. The severe pains in the joints and 
muscles are often sufficient to account for the bad nights com- 
plained of ; but even with those who do not suff'er much from this 
cause, sleeplessness is a distressing symptom up to the crisis. 



ORDINARY OR MODERATELY CONGESTIVE FORM. 



5 



A remission on the third day is very common. It occurred 
in all the cases, which I have had an opportunity of attentively 
observing from the invasion onwards. 

On, or about the fifth day, there is an evident manifestation of 
the violence of the disorder being expended ; and this change for 
the better is often very sudden and complete. One day, we hear 
the patient moaning and groaning in pain; and on the next, he 
is at ease and cheerful, his only complaints being of hunger and 
weakness. This state is generally ushered in by a copious sweat ^ 
or by epistaxis or diarrhoea. The sweating was by far the most 
common critical evacuation till the beginning of October, when 
diarrhoea and dysentery, formerly rare occurrences, became com- 
mon; and at the present time (October 80) they are as usual as 
sweating. After this change, the pulse, tongue, and skin are 
quite natural ; and the facial bronzing often becomes much less 
striking. For several days, or till about the fourteenth or fif- 
teenth day of the disease, there is a period of intermission, dur- 
ing which a great deal of lost strength is regained, and a steady 
improvement goes on in all respects. 

On, or about the fourteenth or fifteenth day from the beginning 
of the disease, the patient relapses; or, in other words, has a 
paroxysm of fever, similar to that which began his first attack. 
The relapse takes place late or early, just according to the date 
of the first convalescence, as will be clearly seen from all the 
cases to be detailed. It sometimes happens, that the onset and 
progress of the second attack is attended by severer, and at 
other times, by milder symptoms than those of the first. In the 
relapse, the abortions most commonly take place.^ In it also, 
the muscular and articular pains are very often most severe. 
Cases, which in the first attack were strictly mild and ordinary, 
have in the second, become signalized by jaundice, dehrium, 
diarrhoea, dysentery, and other grave symptoms. Such occur- 
rences are, however, not common. 

A large number of patients have a second and generally mild 
relapse, on or about the 21st day. As these relapses take place 

' In one or other of the attacks, pregnant women ahnost invariably miscarry. My 
assistant Mr J. W. Reid attended a Dispensary patient who did not miscarry, till a 
necond relapse about the 21st day. 



6 



ORDINARY OR MODERATELY CONGESTIVE FORM. 



often after dismissal from the Hospital, it was some time before 
I discovered the frequency of third attacks. 

In those who are young and of good constitution, the conva- 
lescence is rapid and complete. In the old and debihtated, it is 
otherwise; but I have never seen any one, old or young, die of 
the ordinary form of the fever. 

The above is a succinct account of the course of the disease 
in its most common form. 

Some cases are subjoined, which, I beg the reader to remark, 
are given, not so much as illustrations of the treatment, as of the 
natural history of the fever. 

Case I. — Summary — First attack — Intermission — Belapse on the 
IQtli day. Treatment; cold to tJie head and aperients. 

Thomas Thomson, a native of Kilmarnock in Ayrshire, aged 
23, single, by trade a shoemaker, with fair complexion, blue 
eyes, good development, and plump healthy appearance, was 

Admitted on IQth September 1843, {seventh day.) He states, 
that he was never in Edinburgh till tv/o days ago, when he ar- 
rived from London; after an ineffectual search for employment. 
During the two days of his sojourn here, he has, during both day 
and night, been lounging about the streets, or lying in com- 
mon stairs. Fortunately, the weather has been waiTQ. He 
states, that he never had an illness before the present; and was 
only once drunk in his lifetime. His appearance indicates 
sobriety, and a good constitution. 

He was seized with rigors and headache, on the 10th; and 
from that time till admission, suffered considerably from the lat- 
ter, and at intervals, from the former. He has had only one 
slight sweat, which occurred on the 8th, being the fifth day in- 
clusive, from the seizure; and on that day, as well as on another 
occasion, (the date of which cannot be accurately ascertained), 
he had slight attacks of epistaxis. He has taken no medicine, 
nor had any kind of medical treatment. 

The pulse is 120, full, and of good strength; the tongue is 
much furred, and moist ; the bowels have not been opened since 
the commencement of his illness ; there is no eruption of any 
description on the skin ; the muscular power seems to be very 



ORDINARY OR MODERATELY CONGESTIVE FORM. 



7 



much enfeebled ; the intellect is clear, and the senses and sensa- 
tions are quite natural. He states, that during the last two 
nights he slept none; but before that, he passed tolerable nights, 
though then suffering more than latterly from headache and ge- 
neral pains. The latter are now very slight, but the headache 
still continues severe. He has no appetite ; he has no cough ; 
the respirations are 1 6 in the minute ; and the chest, which is 
broad and well formed, expands freely. The diaphragm des- 
cends easily, and without exciting any unpleasant feelings. He 
has never had nausea, and at present has no epigastric pain ; 
but he suffered a good deal from this cause before admission. 
There is no increased dullness or fullness in the region of the 
liver. His countenance indicates excitement ; it is flushed with 
a deep red, tending to purple, and does not exhibit much of 
the bronzing. — Alradatur capilitkm^ et applicetur aqua frigida 
ioto capiti. — Haheat statim enema purgans; et vespere^ sumat olei 
ricini, Mss. 

18th Septemher, (ninth da^.) — Some hours after the applica- 
tion of the cold cloths, the headache became m^uch less severe ; 
and when reported yesterday at noon, he said, that it had en- 
tirely left him. He was freely purged by the enema and the 
castor oil. The tongue, skin, pulse, and general apect, are na- 
tural; and now, his only complaint is of debility. — Quiescat. 

20th September, (eleventh day^ — He experienced no change till 
this morning, when between four and six o'clock he had some 
rigors. They were not followed by sweating, but by a comfort- 
able and moist state of the skin which exists at present. He 
again feels as well as yesterday. The tongue is clean; the pulse 
is 84, and of good strength; the bowels are confined. — Haheat 
olei ricini §^ss statim. 

2Uh September, (fifteenth day.) — Since last report, he has gone 
on steadily improving. The bronzing has completely replaced 
the flushing. 

25th Septe/tnler, 10 p.m., (sixteenth day.) — About eight p.m. he 
was seized with rigors and headache, followed by a feverish heat. 
At present, he is shaking and trembling as if with cold, but the 
sensation communicated by applying the hand to any part of the 
body is that of burning heat. The pulse is 92. — Quiescat. 

26th September, (seventeenth day.) — He slept pretty well during 



8 



ORDINARY OR MODERATELY CONGESTIVE FORM. 



the night. To-day, he complains very much of headache, and of 
severe general pains; the bowels are open; the pulse is 96, and 
of good strength. — Quiescat. 

27th September, (eighteenth day?) — He slept little during the 
night, which he attributed to the severity of the muscular and 
articular pains. The headache is not much complained of ; the 
bowels were opened, but not freely, this morning, w^ithout the 
aid of medicine ; the skin is cool ; the tongue is slightly coated, 
and rather dry; the thirst is excessive. — Habeat enema purgans 
vesper e. 

28th September, {nineteenth day.) — The bowels were very freely 
opened by the purgative enema. The pulse is 106, soft, and very 
compressible. The tongue is much as it was yesterday. — Habeat 
vini rubri ^iv. 

29th September, {twentieth day.) — During last night, he slept 
well, and sweated profusely. The countenance wears the same 
aspect as yesterday. He feels much better, but still complains a 
little of headache and general pains. The pulse is 88, and of 
rather better strength than yesterday ; the tongue is moist, and 
slightly blackened, as if smeared with black currant jelly, (an ap- 
pearance frequently observed in the patients, and especially, 
though not exclusively, in those who get wine) ; the bowels are 
open. — Quiescat ; — et continuatiir mniim. 

2d October, {twenty-third day.) — He is in every respect well, 
and makes no complaint, except of weakness. This, however, 
does not exist to any great extent, as just before this report was 
commenced, he was seen to walk steadily to the water-closet, a 
distance of about twenty yards, and return to bed, without 
appearing fatigued in the least degree. — Omitatur mnum. — To 
have fidl diet. 

9th October, {thirtieth day.) — There has been a steady and ra- 
pid improvement in appearance and strength, since last report ; 
and he is now dismissed, strong, and in perfect health. His 
destitute condition has been the cause of his remaining in the 
hospital so long after recovery. 



ORDINARY OR MODERATELY CONGESTIVE FORM. 



9 



Case II. — Summary. — First Attack — Remission on the Scl day — 
Intermission — Relapse {more severe than the first attack) on the 
\^th day. Treatment-; wine and aperients. 

Felix O'Neill, Irish, married, aged 52, a pensioner receiv- 
ing Is. Oid. per diem, residing in the Grassmarket, moderately 
robust, with light-brown hair, and grey eyes, was 

Admitted on lO^A August 1843, {fifth day.) — He states, that 
he has never suffered from want of food; and is only occasion- 
ally drunk on pension days. Sixteen years ago, he had fever in 
Queensberry House Hospital, but with this exception, has always 
enjoyed excellent health. His wife and children are at present 
suffering from the epidemic. On the floor above his lodging, there 
occurred several cases, before it appeared in his family. 

On the 6th, he was seized with rigors, headach, general pains, 
prostration of strength, loss of appetite, vomiting, dimness of 
sight, and vertigo. On the night of his attack, he walked to the 
Southern Dispensary, where he received an emetic and a purga- 
tive. He took the purgative, by which the bowels were freely 
moved next morning. He slept soundly, and , perspired a good 
deal during the night. After the operation of the purgative, he 
took the emetic. From the period of seizure, to the present, he has 
had a continuance of the symptoms of invasion in greater or less 
intensity, but upon the whole, varying little in degree, except 
on the 8th, {third day)^ when they experienced a notable re- 
mission. He has had no epistaxis. 

The pulse is 106, full, and of good strength; the tongue is 
clean, and upon the whole, moist; there is much thirst; the 
bowels have been opened by medicine taken this morning ; the 
body is covered with a profusion of small dots of ecchymosis, 
which may possibly have originated in flea bites ; the intellect 
is clear ; there is some headach ; he has slept none for the last 
two nights ; the urine is copious, and high coloured ; the respira- 
tions are 28 in the minute; the diaphragm descends freely; 
his chief complaints are of debility, general pains, and a disagree- 
able saline taste in the mouth. — Quiescat. 

11th August, {sixth day.) — It appears from his own account, 
and from that of the nurse, that he passed a restless, and almost 

c 



10 



ORDINARY OR MODERATELY CONGESTIVE FORM. 



sleepless night. He complains of great thirst, general uneasiness, 
and some headach. The pulse is 92, soft, and of tolerable 
strength ; the respirations are as yesterday ; he has had 
several stools since admission. — Applicetur aqua frigida capiti. 
— Pro potu haheat " imperial.'''' 

12th August, (seventh day^ — From a mistake on the part of 
the nurse, he got a dose of castor oil : the bowels have in conse- 
quence of this been repeatedly moved. He passed a restless, 
uncomfortable night, but notwithstanding, feels rather better 
than yesterday. The pulse is 98, and rather feeble. — Haheat 
vini ruhri "^vj. 

Vespere. Immediately after the noon visit, he had rigors, which 
recurred during the evening, and exist to some extent at present. 

l^th August, {eighth day.) — He slept well, and has an improv- 
ed appearance. He has taken six ounces of wine since 4 p.m. 
yesterday. 

14^7* August, {ninth day^ — He is going on well, and makes no 
complaint, except of the general pains. The tongue is cleaning ; 
the bowels are confined. — Contr. mnum. — Ht. statim olei ricini 
^iss. 

16th August, {eleventh day.) — He is going on well. Since 
the operation of the oil ceased yesterday, he has had no stool. 
Complaints are made of general pains and debility : the sever- 
ity of the former has, however, greatly diminished. — E,. ^:>«7. 
hydrargyri, pil. colocynth. comp. massw dd gr. iiss. Misce, et fiat 
pil. hord somni sumenda. — Cras 7nane, haheat haust. cathartici 

20th August, {fifteenth day.) — Relapsed yesterday. The medi- 
cine prescribed on the 16th was taken, and produced the desired 
result. He went on improving, and without taking any drugs, 
or being confined to bed, till yesterday at 6 p.m., when he was 
seized with pain in the abdomen, and rigors. The rigors continued 
till midnight, and, when he was visited at 9 p.m., were attended by 
a good deal of cold clammy perspiration. The pain left the ab- 
domen this morning after the operation of a dose of castor oil 
taken last night. In the relapse, the general pains have re- 
turned with more than their former severity. — Quiescat. 

21st August, noon, {sixteenth day.) — He fell asleep at midnight, 
awoke at 5 a.m. much refreshed, and at present, feels much better 



ORDINARY OR MODERATELY CONGESTIVE FORM. 



11 



than yesterday. During sleep, he perspired pretty freely, and 
the skin is at present soft and natural. The tongue, which m 
moist, has a streak of yellow fur on its centre. The pulse is 76, 
and of a good character ; the pains of the limbs are much reliev- 
ed ; the countenance, and bowels are natural ; the appetite has 
returned. — Quiescat. 

'2>2d August^ {seventeenth day.) — He slept well, and is free from 
pain, except in the left knee. He had during the night copious 
sweats, (not preceded by rigors,) which afforded no relief to 
his sensations of uneasiness and general soreness. The tongue 
is brown and dry, and he has much thirst, accompanied by ano- 
rexia, and a saline bitter taste in the mouth; the skin is hot, and 
dry; the pulse is 108, and rather small; the countenance is pale, 
and rather depressed; the bowels have been slightly opened; 
he is still taking the allowance of wine formerly ordered. — Statim 
sumat pulv. jalap, comp. 7yi. — R. nitrat. potassw 3^, spir. cetli. nitr. 
C)SS, aquas acetatis ammoniw^ misturw campJiorw^ dd ^iv. Misce. 
Sumat §S5 4<td quaque hord. — Contr. vinum. 

23d August, (eighteenth day.)— He slept none last night, from 
pain in the knee. The pulse is 110, full, and compressible; the 
tongue is coated with a moist yellow paste ; he has much thirst, 
and complains of a disagreeable saline taste in the mouth ; the 
skin is hot and dry. 

Vespere. — He has had several stools, both before and after the 
forenoon visit, and is at present restless from abdominal uneasi- 
ness. — JStatim haheat enema amyli c. sol. mur. morphias Zi- 

24!th August^ {nineteenth day.) — He did not get the enema of 
starch and morphia, but by mistake a domestic enema was ad- 
ministered, which was destined for another patient ; at present, 
he has no diarrhoea. He slept well ; the pulse is 1 08, and of 
moderate strength ; he feels better, but complains much of debi- 
lity. — Quiescat. 

25th August, {twentieth day.) — At 2 p.m. yesterday, he began 
to perspire profusely, and continued to do so till midnight, sleep- 
ing the most of the time. The skin is at present hot, and dry ; 
the tongue is moist, but is still partially covered in its posterior 
and central parts, with a dirty yellow paste ; he has much 
thirst; the pulse is 116, and rather feeble; the bowels are open; 



12 



ORDINARY OR MODERATELY CONGESTIVE FORM. 



the general pains have been much relieved, since friction was 
made some hours ago, with soap and opium liniment. — A pint of 
ale is now ordered, and Ms daily allowance of imne reduced to three 
ounces. 

August, {twenty-first day.) — He slept well; sweated none; 
feels better ; and is free from pain. The tongue is cleaning, and 
moist ; there is no thirst ; the skin is natural ; the pulse is 80, 
regular, but feeble. — Quiescat. 

27t7i August, (twenty-second day.) — He slept well last night, 
and to-day feels better in every respect. 

10th September, (thirty-sixth day.) — Since last report, he has 
gone on steadily improving, and is now dismissed in perfect health. 

Case IH. — Summary. — Admission on the second day of the fever. — 
Remission — Eelapse. Treatment; aperients, hydriodate of potash, 
and wine. 

John Mullans, a Scotchman, married, aged 32, a tailor, 
residing in Eattray^s Close, of spare habit, and dark complexion, 
was 

Admitted on 22^^ September 1843, (second day.) He states, 
that he has been always in tolerably comfortable circumstances, 
and generally in the enjoyment of good health. His wife is at 
present convalescent from an attack of the prevailing epidemic 
fever. 

On the 21st, (yesterday), when sitting at the fireside, he was 
suddenly seized with chills, rigors, headach, and pain in the 
back. He continued in this state for about twenty minutes, when, 
after a few minutes more of uncomfortable heat and restlessness, 
a profuse perspiration broke out on the upper part of his body, 
the sweat falling in large drops from his forehead and face. He 
went to bed in this condition, and slept a good deal at intervals 
during the night ; but awoke this morning in no degree refreshed, 
and oppressed with feelings of lassitude, and general soreness. 

The face is distinctly bronzed ; and the expression indicates 
anxiety and suffering ; the pulse is 126, full, and soft ; the 
tongue is white and moist ; there is not much thirst ; the bowels 
were opened once yesterday, but not to-day ; the skin is hot, and 



ORDINARY OR MODERATELY CONGESTIVE FORM. 



13 



dry ; there is no eruption of any kind on the skin ; his intellect 
is clear ; he has very severe headach ; he feels very weak ; he has 
some cough, and severe muscular and articular pains ; but no pain 
in the chest or abdomen. — Let the head he shaved^ and cold water 
diligently applied to its ichole surface, till the headach is relieved. 
— Habeat enema purgans statim. 

2Sd September {third day.) He slept none during the night ; 
the head has been partially relieved by the cold applications ; 
the pulse is 120, and strong. At present, he is bathed in perspi- 
ration. The bowels were opened by the enema. — Admoveantur 
hirudines m temporihus. — Habeat hord somni solutionis muriatis 
morphicB gtt. ooxv forma haustus, 

2^th September {fourth day.) Only one of the leeches fastened, 
and very little blood w^as obtained by it ; the headach, however, 
has been greatly relieved by the assiduous use of cloths, soaked 
in cold water. The pulse is 116, and smaller than yesterday. 
The skin is very hot ; the general pains are very severe, and are 
especially acute in the shoulders, back, and knees ; there is some 
abdominal pain, but it seems to be muscular ; some pale yellow fur 
coats the tongue, which is painful, and of a bright red colour at 
the point, where the papillse are seen appearing above the fur; 
the bronzing of the countenance is even more decided than on ad- 
mission ; he has had no stool since yesterday. — Habeat olei ricini 
^iss statim ; et hord somni, enema amyli cum solutionis muriatis 
morphice "hi. — Let the cold applications be assiduously continued. 

I^th September {fifth day.) The castor oil and the enema were 
given as ordered ; and the cold water has been very diligently 
applied to the head. The headach is almost gone ; the tongue 
continues moist, and is cleaner than formerly. — Bepetatur enema 
amyli cmn solutionis muriatis morphice '^iss, hord somni. 

26th September {siooth day.) He slept well last night, and feels 
very comfortable to-day. — Quiescat. 

27th September {seventh day.) He slept well last night. In the 
afternoon of yesterday, he had two sweats, before which, he felt 
uncomfortable, but after which, he experienced great relief. The 
bowels are confined ; there is no abdominal uneasiness ; there is 
still a good deal of thirst; the bronzing is particularly well 
marked. — Habeat enema purgans node. 



14 



ORDINARY OR MODERATELY CONGESTIVE FORM. 



28^A Septemher, {eighth day) Last night, the bowels were 
freely opened by the enema. The bronzing of the face is more 
striking than it has been ; and the cheek on which he has been 
resting, has exactly the pecuhar purple colour of a ripe apricot. 
There is some improvement in the expression of the countenance; 
the pulse is 104, and rather deficient in strength; the tongue is 
clean, but dry and parched. He has no headach, except when 
he sits up suddenly, which causes temporary throbbing and 
aching in the temples. He has some slight pains in the 
knees, and some rather severer in the shoulders. — Habeat vini 
ruhri ^iv. 

29th September, {ninth day) He has had some sound and 
refreshing sleep during the night ; and at present, has a tend- 
ency to slumber, which was also exhibited yesterday. The pulse 
is 80, and of better strength ; the tongue is moist, and, except 
at the point, has a thin coating of yellowish fur. Sudden move- 
ment of the head still excites throbbing and pain in the temples, 
but not to such an extent as yesterday. He has had no stool 
since the evening of the 27th ; there is neither pain nor uneasi- 
ness in the abdomen. — Habeat statim puheris jalapw compositce 
Ziss ; et vespere, enema domesticum si opus sit. 

1st October, {eleventh day.) The bowels were freely opened by 
the medicine, the day before yesterday. He has been improving 
since last report. Last night, he slept well. At present, he 
makes no complaint. The pulse is 64, and of moderate strength. 
— Quiescat. 

2d October, {twelfth day.) He passed a good night ; and is 
much better than he has yet been. He has still very much de- 
bility, as has just been shown by the unsteady tottering step with 
which he walked down and up the ward, to exhibit the degree 
of strength which he possesses. — Quiescat. 

Sd October, {thirteenth day.) Since yesterday, he has gained a 
little strength. 

4ith October, {fourteenth day.) He was up for nearly two hours 
yesterday. He passed a good night, and has no remaining 
symptoms of the fever excepting the debility, (which is daily 
diminishing,) and a little of the facial bronzing. 

5th October, {fifteenth day.) At 3 o'clock this morning, he 



ORDINARY OR MODERATELY CONGESTIVE FORM. 



15 



relapsed, having at that hour been seized on awakening from 
sleep, with rigors and headach. The rigors recurred several times 
before nine this morning, and were latterly associated with ardent 
fever. At the first seizure, he felt cold ; and the nurse, at his 
request, put on two additional blankets. He has not sweated 
yet ; but the skin has at present a tendency to moisture. Thirty- 
six hours have elapsed since his bowels were moved ; the tongue 
is moist, and coated with a white fur; the pulse is 112, and of 
good strength; at present, the headach is very slight; and with 
the relapse, he has not as yet had any muscular or articular pains. 
— Intermittatur mnum. — Habeat statim olei ricini ^iss. — To have 
the limbs bathed in hot water at \Q p.m. 

Qth October^ {sixteenth day.) The bowels were opened by the 
medicine last night. He had some refreshing sleep, and gentle 
perspiration during the night. Since the last report was made, 
at noon yesterday, he has felt comfortable till now, when a 
slight chill, rigors and headach, have thrown him back. The 
tongue is clean and moist. He has some pain in the right thigh 
and left shoulder joints. — R. hydriod. potassw Zii, infusi gen- 
tianas ^iv. M. et solve. Habeat l,ii ex aqua ter in die. 

1th October^ {seventeenth day.) To-day, the headach and general 
pains are very severe. — Continuatur mistura hydriodatis potasses. 
— Apply cold water diligently to the head. 

8th October, {eighteenth day.) The headach was soon relieved by 
the cold water. He slept none during the night, from severe pains 
in the shoulders, and through the body generally. At present, 
the least movement in bed causes great pain; the bowels are 
open ; the tongue is white, and moist ; the pulse is 120, and of 
moderate strength ; there is much thirst. — Continuatur mistura. 
TJtatur linimento saponis cum opio. 

9th October, {nineteenth day.) After the free use of the soap 
and opium liniment, he slept well, and has enjoyed for the last 
twelve hours almost complete respite from the muscular and ar- 
ticular pains. His only complaint is of debility, which exists in 
a greater degree than in the majority of the patients. — Intermit- 
tantur mistura et linimentum. — Habeat vini rubri ^iv. — Common 
diet. — Allowed to rise for an hour. 

22</ October, {thirty-second day .) — Since last report, he has been 
gradually, but slowly gaining ground. Pains in the shoulders, 



16 



ORDINARY OR MODERATELY CONGESTIVE FORM. 



thighs, and ankles have occasionally slightly molested him, and 
do so to some extent to-day. On the 13th, his wine was stopped, 
and a quart of porter substituted ; on the same day, he began 
full diet ; the porter is now stopped. 

24ith October^ {thirty-fourth day.) — He is dismissed, free from all 
complaint, except of some pain and stiffness in the left thigh 
joint. He has greatly regained his lost strength. 

Case IV. — Summary. — First attack — Remission — Relapse on l7th 
day — Heroes labialis — Sudamina. Treatment ; Aperients^ Sfc. 

Harriet Rose, aged 26, of English parents, born in Edinburgh, 
a fancy fruit and flower worker, the wife of a strolHng Italian 
organist, (resident in a lodging-house in the Grassmarket since 
May last,) wdth black hair, blue eyes, and spare development, 
was 

Admitted SOth September 1843, {fifth day.) — She states, that 
though her general health is not robust, yet she seldom has 
severe illness, and, excepting the present attack, does not recol- 
lect of having had any serious disorder since childhood. 

For two or three days before the 26th, she felt languid and 
feverish ; and on that day, suffered a good deal from sickness, 
vertigo, headach, and pain in the back. During the two follow^- 
ing days, she continued to have more or less vomiting. On the 
28th, she got an emetic from a dispensary pupil. She has had no 
opening medicine. 

The expression is good ; the face is suffused wath a purple 
colour; the pulse is 126, and small; the tongue is w-hite, and 
moist ; the bowels are open ; the temperature is increased ; 
there is no eruption on any part of the body, excepting on the 
lips, where there is much herpes labialis ; the intellect is clear ; 
she complains of vertigo, headach, a bad taste in the mouth, and 
muscular debility. There is a distinct Turner's line extending 
from the ensiform cartilage to the pubes. She was confined five 
months ago, and has nursed her infant up to the invasion of the 
present disorder. Her milk has been scanty. She has not men- 
struated since her confinement. — Ahradatur capillitimu, et diligen- 
ter applicetur aqua frigida toto capiti. 

1st October, {sixth day.) — The headach was relieved, but not 



ORDINARY OR MODERATELY CONGESTIVE FORM. 



17 



removed, by the application of cold water. She has had a good 
deal of vomiting and diarrhoea: the former ceased, after drinking 
some lemonade ^ the latter, after a dose of the decoction of log- 
wood. 

2d October, (seventh day^ — The countenance is improved ; and 
she feels better to-day. The pulse is 120, and of good, strength; 
the bowels are confined ; the tongue is much the same as on ad- 
mission; the skin is hot, and dry; the causes of complaint are 
great thirst, and pain in the shoulders. — Sumat statim pilulam 
colocynthidis compositce j. 

Sd October, (eighth day.) From her own statement, and that 
of the nurse, it appears, that she has been very restless, hot, 
and uneasy, since last report, frequently wakening in a fright 
from disturbed slumber. At present, she complains of confusion 
of ideas, and general coldness of the surface : the countenance 
is abstracted, and little if at all depressed; the conjunctivae are 
injected, and the eyes streaming with tears ; the pulse is 98, 
and rather weak; there is neither headach nor pain in any part 
of her body. The pill produced no stool. — Vespere, sumat olei 
ricini ^i. 

4^th October, (ninth day.) When seen last night, she was suf- 
fering much from cough, and oppression at the chest. The ap- 
plication of a sinapism to the thorax has removed both these 
symptoms. The bowels have been opened by the castor oil; the 
countenance is much improved; the pulse is 96, and of good 
strength; there is great complaint made of general pains in the 
muscles and joints; moving in bed causes much suffering, and is 
attended with great difficulty, the limbs being at times quite 
powerless; when at rest, she feels easy, and comfortable. — 
Quiescat. 

6th October, (eleventh day.) The tongue, skin, pulse, and coun- 
tenance, are natural, excepting that the latter is bronzed. Her 
strength is returning. — Quiescat. 

8th October, (thirteenth day.) There has been progressive im- 
provement since last report. The general pains and stiffness of 
the joints, however, are such as to render it impossible for her to 
put on her clothes, otherwise, she might be out of bed with ad- 
vantage. — Quiescat. 

I2th October, (seventeenth day.) The improvement was going 

D 



18 



ORDINARY OR MODERATELY CONGESTIVE FORM. 



on steadily, till last night about eight o'clock, when she was 
seized with headach, rigors, and subsequent sweating. She 
slept ill during the night. At present, there is no headach; the 
pulse is 184, and of moderate strength; the tongue is coated with 
a thin, brown, moist fur; there is much thirst; the bowels are 
open; the skin is hot, and dry. — Quiescat. 

ISfh October, {eighteenth day?) Early this morning, she was 
seized with rigors, followed by cold perspiration. Since that 
time, she has had numerous chills, with trembling and shaking 
of the body, followed by cold sweats. At present, she is very 
uncomfortable; and has a cold clammy moisture on the skin; 
the pulse is natural, the tongue is clean and moist; the bowels 
are open; there is considerable cough; both cheeks have the ripe 
apricot appearance to a striking extent. — R. lincti opiati ^ij. 
Habeat 1)% j)to dose, tiisse urgente. 

1 Uh October, {nineteenth day?) Since yesterday, she has almost 
constantly had profuse cold sweats on the upper part of the body, 
excepting the arms, as far down as the epigastrium. The chest 
exhibits a most beautiful example of sudamina ; thickly set, on 
the whole of the anterior and lateral walls of the thorax, are an 
infinity of white vesicles of the average size of a pin's head, giv- 
ing to the surface, at a short distance, a soft chalky appearance. 
Vesicles of the same description are also pretty abundant upon 
the neck and abdomen, a very few are to be seen on the thighs, 
and there are none on the arms or legs. The sweat at present 
on the surface, particularly that on the chest, intensely reddens 
litmus paper. The bowels are open; there is some cough. — Con- 
tinuatur linctus, 

15th October, {twentieth day,) The sudamina have entirely dis- 
appeared, and the sweating ceased; the oppression at the chest, 
and cough, have greatly increased. — Omittatur linctus. — R. olei 
crotonis tiglii, olei olivarum dd 7>iij. Misce. Signetur. The half 
to be rubbed in on the anterior surface of the chest this evening, and 
the rest to-morrow morning. 

l^th October, {twenty-first day) The cough and oppression are 
somewhat easier. The surface to which the croton oil was ap- 
plied is red and itching. She is gaining strength, and has a 
good appetite. — Let two drachms more of the liniment be rubbed 
into the same surface. 



ORDINARY OR MODERATELY CONGESTIVE FORM. 



19 



1 ItJi October^ {twenty -second day.) A copious crop of very small 
pustules has been brought out by the croton oil. There is hardly 
any cough, and no oppression on the chest ; the general pains 
are much relieved, and in every respect, she is much better. — To 
have full diet. 

21s^ Octoher^ {twenty-sixth day.) Since last report, she has been 
rapidly gaining strength. She is now dismissed, free from every 
complaint. 

Sth November. — Since dismissal, she has been much in the 
Hospital in attendance upon her husband. She suffers from 
oedema, pain, and stiffness of the legs, with general debility; but 
has a good appetite, and is in other respects well. 

Case V. — Summary. — First Attack — Intermission — Relapse on the 
l^th day.) causing abortion — denial of pregnancy — bronchitis 
in both attacks. Treatment ; blister to the chesty morphia and 
ipecacuanha lozenges^ and aperients. 

Lucy Gartlan, Irish, single, aged 22, a field worker, residing in 
the High Street, of short stature, and strong conformation of 
body, with red hair, and light eyes, was 

Adraitted on September 9, 1843, {third day.) She states, that 
up to the moment of her seizure, she had plenty of food, and was 
in full employment. She has always enjoyed perfect health. 
The epidemic fever is at present in the house where she resides. 

On the 7th, without any premonitory symptoms, she fell down 
in a state of exhaustion, when at work in the fields, exposed to 
a strong midday sun. Immediately afterwards, headaoh, gene- 
ral pains, and vomiting set in, which along with sleeplessness, have 
continued with considerable severity till now. She had no rigors 
at the invasion of the disease, and very little sweating. She has 
had no medical treatment, nor done anything for herself, beyond 
taking a dose of sulphate of magnesia; the expression of counte- 
nance is excited and restless; the pulse is 110, full, and strong; 
the tongue is dry, and coated with a white fur; there is much 
thirst; the bowels are confined; the skin is dry, and the temper- 
ature of the body much increased; the intellect is clear; the 
headach is intense; the muscular and articular pains are severe; 
the taste is vitiated, and somewhat saline; the muscular power 



20 



ORDINARY OR MODERATELY CONGESTIVE FORM. 



is depressed; there is some cough, and bronchitis; there is no 
abdominal uneasiness. From the bulkiness, and form of the 
abdomen, there seems to be good reason to believe, that she is 
pregnant, although she indignantly denies the possibility of such 
a thing. — Haheat trocMscarum morpMce et ipecacuanTiw I. Sig. 
One occasionally^ lolien the cough is troublesome. — Apj)licetiir vesi- 
catorium ijectori. 

12th September^ (sixth day?) The cough and bronchitis have 
left her; and since a sweat yesterda}^ she has had no un- 
pleasant feehngs of any kind, excepting a slight pain in the left 
shoulder-joint. The tongue, pulse, and skin are natural. She 
still stoutly denies being pregnant ; but offered no objection to 
the examination which was deemed necessary to elucidate this 
point. The mammge are flabby, and neither turgid nor knotty. 
The nipple lies depressed in a slit-like sulcus in the centre of the 
areola. Both areolae, but particularly the right one, are of an 
unusually deep colour for a virgin, which the patient professes to 
be. The abdomen is smooth, as in women who have never borne 
children ; the integuments have a tense appearance, and exhi- 
bit no trace of the dark line.^ Two fingers have now been car- 
ried up to the OS uteri, and trial made of the internal repercus- 
sion test. The pat with which the tumour fell back on the 
fingers, after it had been jerked upwards, leaves no reasonable 
doubt as to the existence of pregnancy. By means of the stetho- 
scope, uterine blowing is heard, and also, (perfect stillness having 
been obtained in the ward), the double tic tac of the foetal heart. 
The only place in which the foetal heart can be detected, is in a 
small space, situated three inches below the umbilicus, and a 
little to the right of the mesial line. Its pulsations are 144 in 
the minute, (or seventy-two double beats), whilst those of the 
mother are 98. She still denies being pregnant; and has exhi- 
bited great indignation, whilst the above report was being dictat- 
ed. — Quiescat. 

^ Mr Tiu'ner of Keith has described (Monthly Journal, vol, ii.) a dark stripe, 
extending from the ensiform cartilage to the pubis, as a sign of recent dehvery. I 
have found, that this is met with in various circumstances, in both sexes. Pai't of 
the above details I'efer to this subject, in the investigation of which I was engaged 
when the cases detailed in this memoir were reported, a circumstance which will ac- 
count for occasional allusions to it. 



ORDINARY OR MODERATELY CONGESTIVE FORM. 



21 



iSth September, (seventh day^ Every symptom of the epidemic 
disorder is at present in abeyance, excepting the bronzing of the 
countenance, which is now more marked than it has yet been. 

Since yesterday, she has confessed to the nurse, the possibi- 
hty of her pregnancy; but stated, that till now she never sup- 
posed herself to be in that condition. She has not menstruated 
for five months. — Quiescat. 

lUJi Septemler, (eighth day.) She continues quite well. — To 
have full diet. 

20th Septemher. Vespere. (fourteenth day.) Till six o'clock this 
evening, she has continued quite well. In the forenoon, the bowels 
having been reported confined, a dose of castor oil was ordered, 
which she took at three o'clock; and at six p.m., in consequence, 
she at first supposed, of the medicine, she felt uneasy feelings in 
the lower part of the abdomen. At present, she has slight bear- 
ing-down pains, and the os uteri is somewhat dilated. For some 
hours past, there has been a flow of a red-coloured discharge 
from the vagina. — Quiescat. 

21st September, noon, (fifteenth day.) After much suffering, she 
gave birth to a still-born male foetus, of apparently six months, at 
half-past three this morning. The presentation was natural ; and 
the placenta came away along with the foetus. There has been 
no hsemorrhage; and she is doing well in every respect, except- 
ing that there is some return of the bronchitis. — Habeat troch. 
morphiw et ipecacuanhw I. 

22d September, 8 p.m., (sixteenth day.) She passed a feverish, 
sleepless night, but has slept a good deal during the day, and is at 
present comfortable. The pulse is 76, and feeble. The chest 
symptoms have almost disappeared. No uterine tumour can be 
felt above the pubis. There is no Turner's fine. — Continuantur 
trochisca. 

2Mh September, (eighteenth day.) She continues to gain strength 
daily. The only complaint is of some slight remains of muscular 
and articular pains. The pulse is 90, and of good strength; the 
tongue is moist; there is some thirst; the skin is natural; the 
cough is almost gone. The areolse are much darker than pre- 
vious to the miscarriage. The discharge is now greenish; it 
has always been scanty, and is so still. The bowels are confin- 



22 



ORDINARY OR MODERATELY CONGESTIVE FORM. 



ed. — To have three seidlitz powders^ and twenty-five more of the 
lozenges, 

SOth Sej)temher, {24<th day.) Since last report, she has gone 
on steadily improving, and is now well and free from all com- 
plaints. — Allowed to 7ise ; and to have full diet. 

4*th October, {28th day.) She is dismissed in the enjoyment of 
perfect health, excepting that there are occasional slight returns 
of the general pains at night. She looks healthy; and has hard- 
ly any trace of bronzing. The abdomen has been examined to- 
day, and almost daily since abortion; but not the slightest trace 
of a dark abdominal line has ever been detected. 

The foregoing cases give a fair view of the Natural History of 
the disease, in its mild or common form. 



HIGHLY CONGESTIVE FORM. 



23 



CHAPTER 11. 

HIGHLY CONGESTIVE FORM OF THE DISEASE. 

Although many of the cases issuing in death, or characterized 
by extreme severity, present symptoms very different from those 
hitherto detailed, there can be no doubt, that the disease is es- 
sentially the same, the difference being one only of degree, as will 
be more specially unfolded hereafter. Both forms are undoubt- 
edly the result of the same morbid poison. 

One of the most common symptoms in the highly congestive 
form of the disease, is yellowness of the conjunctivae, and of the 
whole surface of the body. It generally appears between the 
third and seventh day, and is always most intense on the face, 
neck, chest, abdomen, and thighs. The hue of the neck and 
chest is the most vivid ; then comes, of equal, or nearly equal 
brightness, the abdomen ; then, somewhat fainter, the thighs ; 
then, considerably paler still, the legs, arms, and fore-arms ; 
the hands and feet get their colour later, always to a much less 
extent, and sometimes not at all. The yellowness occasionally 
appears during the relapse, and not in the first attack. I have 
seen it present in both. 

Associated with the yellowness, there are generally depression, 
less or more delirium, dusky, and often porter-coloured urine, 
black melsena-like stools, and heemorrhages- fr|)m some of the mu- 
cous membranes. In the worst of the cases, black coffee-ground- 
like matter is ejected from the stomach, and passed per anum. 

In some cases, the black vomit occurs without the yellowness ; 
and, on the other hand, at the autopsy of yellow patients who 
have had no black vomit, this matter has been found in the 
stomach, and other parts of the alimentary canal. 

Enlarged liver and spleen, and tender and tympanitic abdomen 
are less constant, but still, very usual symptoms in cases cha- 
racterized by yellowness or extreme congestion. Difficult mic- 



24 



HIGHLY CONGESTIVE FORM. 



turition has been complained of by several of my yellow and 
purple patients. 

A deep persistent purple colour of the face, appearing before, 
or immediately after the invasion of the disease, is a certain prog- 
nostic of danger, and is seldom absent in those destined to be 
yellow. Since I first made this observation, it has received, 
among others, two notable verifications in the cases of my assis- 
tant, Dr Heude, and Mary Wallace, one of the nurses. Dr Heude 
I pointed out to my other assistant, Mr Reid, as deeply purple at 
noon, when we were engaged with the visit: — at 3 p.m. he was 
in the initial paroxysm of the fever. Mr Reid and I remarked 
Mary Wallace becoming first bronzed, and at last purple, before 
she was laid up, and in consequence advised her to take the 
chlorinated solution, which she did not do. Both became yellow, 
and both narrowly escaped with their lives. 

With the exception of the purple countenance, the symptoms 
which usher in the congestive form of the disease, differ little 
from those attending the disorder in its milder degree. As has 
already been remarked, there is some considerable difference in 
the eases as to the time at which the yellowness appears. 

G-enerally, in the severe cases, there is merely a remission 
about the seventh day, but no intermission; and even in those 
who died a few days later, a slight amendment was noticed 
about the usually critical period. 

In my dissections of the purple and yellow cases, I have uni- 
formly found bile in the gall-bladder, a pervious state of all the 
bile ducts, and bile in the duodenum. Excessive capillary con- 
gestion was always met with; and in the severe cases, exuded 
blood was found between the muscular and mucous coats of the 
intestines. The pathological details, however, it will be more 
convenient fully to analyse and consider, after the subjoined re- 
ports, which, I may state, describe the whole of the highly con- 
gestive cases admitted into the New Fever Hospital, during the 
period of my Physicianship.^ These reports are given, (with a few 
verbal amendments), verbatim, as they were dictated by myself 
at the bedside, and in the theatre of anatomy : in not one in- 
stance have I ventured to supply defective reports from impres- 
sions remaining after the lapse of days or even hours. 

^ See the Tables in the Appendix. 



HIGHLY CONGESTIVE FORM. 



25 



Case VI. — Summary. — Purple countenance — epistaxis — hlack 
vomits witJiout yellowness of the skin — slight impromment on the 
semnih day — Death on the tenth day. — On Dissection^ the Hie ducts 
were found pervious^ and the gall-bladder contained inspissated hile; 
the gasfro-intestinal mucous membrane was here and there dark- 
coloured, with submucous exudation of blood in patches; a consi- 
derable quantity of black matter, similar to what was vomited dur- 
ing life, was found in the stomach, oesophagus, pharynx, and poste- 
rior nares. 

James Law, a Scotchman, widower, aged 74, a spare broken- 
down old man, with light hair and eyes, was 

Admitted on 9th August 1843, (fourth day of the disease^ — His 
occupation has been that of a labourer; but for the last eighteen 
months, he has been an inmate of the House of Refuge, where he 
states, that he had enough of food. 

On the 6th August, he was seized with rigors, without head- 
ach. There was fever at this time in the House of Refuge. 

His face is of a deep purple colour; the expression is not 
anxious; he complains of general pains, great muscular de- 
pression, and slight cough ; the pulse is 68 ; the tongue is mo- 
derately moist, clean, and very red at the point: there is no 
eruption on the skin, which is moist ; he is drowsy, but has no 
headach ; he has had no epistaxis, nor other haemorrhage ; the 
bowels are open. — Quiescat. 

10th August, {fifth day?) The tongue has become dry through- 
out, and furred behind ; the pulse is 78, and stronger than yes- 
terday ; the bowels are slow. — Habeat olei ricini ^i, statim. 

12th August, (seventh day.) The bowels have been moved by 
the medicine; the skin is moist; the pulse is soft, and natural; 
and the tongue is cleaning. He was restless, and raved some- 
what during the night. — Habeat vini rubri 'siv. 

Vespere, He is more incoherent. Thero has been some epis- 
taxis from both nostrils. Some time after this, he fell, when 
crossing the ward to the water-closet, — which, from there being 
no night-chairs or bed-pans as yet in the hospital, the patients 
are obliged to visit, when quite unfit for such exertion. 

E 



26 



HIGHLY CONGESTIVE FOEM. 



IZth August^ (eighth day.) To-day, the countenance is greatly- 
depressed ; the pulse is 80, and feeble ; he has had copious dis- 
charge of black fluid blood from the mouth and nostrils — what 
was collected, measures twenty fluid ounces, (apothecaries' 
measure,) but, from the soaked appearance of the clothes and 
bedding, it is evident, that a considerable additional quantity has 
been lost. This hsemorrhage commenced at 10 p.m. last night, 
(when the nostrils were plugged, and other measures taken for 
arresting it,) and continued to a greater or less extent, till 
half-past eight this morning, when it somewhat abated. At 
half-past twelve noon, he could hardly articulate, and the pulse 
was excessively feeble; but before the visit was completed, it 
had become 78, and rather firmer, soon after getting a little 
negus. Then, also, he could articulate, though indistinctly. He 
has taken about five ounces of wine since the visit yesterday. — 
R. acetatis phmli gr. xxiv, aquce distillatw ^m. Solve. Habeat 

sextet qudque hora.. — Continuatur mnum ad ^vi ; the wine to 
he given cautiously. 

Half-past nine p.m. He has had a little more epistaxis since 
the forenoon visit, and has vomited eleven fluid ounces of a dark- 
coloured fluid, exactly resembling coffoe-grounds. He has slept 
from noon till now, excepting when disturbed by the vomiting ; 
but his sleep was broken. The pulse is 80, soft, and compressi- 
ble, but fully as firm as at the forenoon visit. None of the mix- 
ture prescribed has been administered. 

14^th August^ {ninth day.) After the evening visit last night, 
he slumbered till half-past four this morning, when he was roused 
by a return of the vomiting, and ejected about three ounces of a 
black fluid, exactly resembling coffee-grounds, and bearing no 
resemblance whatever to blood. After this, he slumbered on till 7 
A.M., when he had an attack of rigors. The nurse states, that he 
had opisthotonos at this time, being quite insensible, and to all 
appearance in articulo mortis. He has at present, some subsul- 
tus tendinum ; he lies on his back, with a collapsed, but easy 
countenance; the breathing is noisy; the respirations 26 in the 
minute; the pulse is about 120, very weak, but varying consi- 
derably as to number within a brief space of time. The impulse 
of the heart is almost imperceptible, and the first sound is in- 
audible; the apex is under the sixth rib. There is strong pulsa- 



HIGHLY CONGESTIVE FORM. 



27 



tion at the epigastrium, and extending in the mesial line, from 
the ensiform cartilage to near the pubes. There is no abdo- 
minal tenderness on pressure; the tongue is dry, and coated 
with a black paste, and the teeth have a similar covering ; the 
pupils are not much influenced by light ; the eyes are suffused, 
and have a somewhat glazed appearance; the voice is husky 
and feeble, but he seems coherent, and answers questions ration- 
ally ; the temperature of those parts of the body which have 
been sufficiently covered is natural, but the feet and other parts 
which have been exposed are cold ; some alvine evacuation has 
taken place, similar in appearance to the matter vomited ; he 
has taken four ounces of the wine, and an equal quantity of the 
acetate of lead mixture. — To have the abdomen fomented with hot 
water ^ and hot bottles applied to the feet. — Continuatur vinum^ et in- 
termittatur mistura. — R. mm. hydrarg. corrosivi gr. iv, opii gr. 
viij\ extracti gentianw q. s. ut fiat massa, in pil. xvi pares dim- 
denda. Habeat unam secundd qudque hord. 

15th August, (tenth day.) He died at half past ten a.m., having 
sunk gradually, and having apparently retained his consciousness 
to the last. He took several of the pills, had no return of the 
vomiting or epistaxis, and no more stools. 

Sectio Cadaveris, l7th August 2 p.m., being fifty-two hours after 
death. 

External Inspection. — The external surface of the body and the 
conjunctivae are found, on minute examination, to have no yellow 
tinge. There are large livid patches on every part of the body. 

Internal Inspection. — Thorax. — The left lung weighed two 
pounds four ounces;^ it was much congested behind, but anteriorly, 
was almost destitute of blood, and in an emphysematous state, 
depending probably upon incipient putrefaction : upon opening 
the thorax, it seemed to fill up about one-half of its own side. 
The right lung weighed two pounds thirteen ounces ; it was con- 
nected by firm adhesions at every point of its surface, evidently 
from inflammation of no recent date. There was scarcely any 
effusion into the pleural cavities ; the pericardium contained an 
ordinary quantity of fluid ; the heart weighed thirteen ounces, 
and exhibited no softening or valvular disease. In the right 

1 Once for all it may be well to state, that the organs are weighed by the impe- 
rial standard weights; and the fluids measured by the apothecaries' fluid measure. 



28 



HIGHLY CONaESTIVE FORM. 



auricle, there was a large well organized firm clot, and also some 
black half-formed clots in the left auricle ; in both ventricles, 
there were some large clots, and the aorta contained a firm 
white clot. 

Abdomen, — The spleen weighed six ounces, and was firm and 
natural in texture, but was certainly under the average bulk. 
The liver, with the gall-bladder and its contents, weighed four 
pounds six and a half ounces, and was upon the whole natural in 
colour and consistence. The gall-bladder was greatly distended 
with bile, resembling treacle, but of a rather darker colour ; it 
was not ropy, but considerably inspissated. The gall-ducts were 
pervious. The duodenum was tinged of a deep yellow colour by 
the bile ; and when this was washed off by a properly direct- 
ed stream of water, the mucous membrane was seen to be inject- 
ed, and diversified with occasional black patches. The greater 
curvature of the stomach was much congested, and there seemed 
to be some extravasation of blood into the submucous cellular 
tissue in that part of the organ. The mucous membrane was of 
natural firmness, excepting at the congested parts, where it was 
much more easily torn by the nail. No ruptured vessel could be 
detected in the stomach, nor indeed in any part of the alimentary 
canal, which was examined in its whole extent. Some black 
matter, similar to what was vomited by the patient during life, 
was found in the stomach, oesophagus, pharynx, and poste- 
rior nares, in which latter situation it was mixed with mucus. 
There was some vascularity and congestion of the ascending and 
transverse portions of the colon, occurring in patches. Under 
these patches, there was seen a well-marked efiusion of black 
blood, into the submucous cellular tissue. There, as in the sto- 
mach, the mucous membrane was firm, excepting at the congest- 
ed parts. Some granular patches were seen on the mesentery, 
but the glands were healthy. The right kidney weighed six and 
a half ounces, and was healthy; the left weighed five ounces, and 
was also of the ordinary aspect, excepting that two hydatids were 
observed on its posterior surface. 

Head. — Upon removing the calvarium, it was found to be 
firmly attached to the dura mater, over the posterior termina- 
tion of the superior longitudinal sinus; and at this part, the bones 
were rough. Under the dura mater and arachnoid membranes, 



HIGHLY CONGESTIVE FORM. 



29 



there was the usual quantity of fluid. The membranes were not 
congested. The brain itself was firm, not vascular, and of a na- 
tural colour. The ventricles contained the usual quantity of 
fluid. The cerebrum weighed two pounds one ounce and a half: 
the cerebellum, pons Varolii, and medulla oblongata, weighed 
conjointly six ounces. 

There was no extravasation of blood into the muscular tissue, 
in any part of the body incised during the autopsy; but no in- 
cisions were made specially for the purpose of determining whe- 
ther such extravasation existed in any other part of the muscu- 
lar system. No yellowness was observed in the muscles, serous 
membranes, bones, or cartilages. 

Case VII. — Summary, — Bpistaxis — jaundice and delirkm — 
Death on the seventh day. — On Dissection, the serous membranes, con- 
junctivce, cartilages of the ribs, <^c. were found to he yellow ; the 
hile-ducts were pervious ; the gall-hladder contained inspissated hile ; 
the g astro-intestinal mucous membrane was dark-coloured, with 
hlack patches, and submucous exudation of blood ; — the internal 
surface of the heart was stained of a deep yellow colour, and the 
organ itself was very soft. 

George Johnstone, a particularly strong and muscular indi- 
dual, a native of St George's, Grenada, aged 20, married, resi- 
dent in Edinburgh only during the last eight days, was 

Admitted 8th August 1843, (third day.) He was seen by Dr 
Craigie on the 8th, and by me, for the first time, on the 9th, when 
it was impossible to obtain the previous history of his disease, 
either from himself or others. 

9th Aiigust, noon, {fourth day.) He complains of pain in the 
temples and abdomen, with general uneasiness. The abdomen is 
greatly distended; the bowels constipated; the skin very dry; the 
tongue moist and foul. He passed a very restless night. — R. 
pulv. jalapce composite^ ^i, calomelanos gr. iij. Misce. Statim sur- 
mat. — Habeat enema domesticum vespere, si non prius solvatur 
alvus. 

Vespere. He feels easier. The powder produced several scanty 
fluid stools. The enema was administered, and immediately re- 



so 



HIGHLY CONGESTIVE FORM. 



jected with force, by the escape of flatus. The abdominal dis- 
tension is considerably diminished. — R. olei ricini, aquae menthce 
pip. da sol. mur. morpMce gtt. xv. Ft. liaustus eras mane 
sumendus. 

lOth August, (fifth day^ He slept a good deal during the night, 
but looks worse than yesterday. The castor oil draught which 
was given at half-past five o'clock a.m., has not yet operated, and 
the tympanitis has increased; the skin is dry, as it was yester- 
day; the pulse is 90, and feeble; the respirations are 42. — Haheat 
enema purgans statim. 

Vespere. From an irregularity, depending upon the defective 
service of the hospital, the injection has not been administered. 
The bowels have not been opened, and the tympanitis has in- 
creased. — Haheat enema purgans statim; et haustum olei ricini^ 
aquce menthce pip. da, "^ij eras mane. 

11th August, (sixth day.) The countenance is less anxious 
than yesterday. He had no relief from the enema administered 
last night ; and the nurse could not prevail on him to swallow 
the castor oil draught this morning. The skin is somewhat 
softer than yesterday; the eyes are suffused; the pupils some- 
what dilated; and there is yellowness of the conjunctivae ; the 
pulse is 68, soft, feeble, and regular; the extent of the tym- 
panitis seems to be the same as yesterday, but there is more 
abdominal tenderness on pressure ; the tongue is dry, but not 
parched, clear at the edges and point, but coated with a brown- 
ish fur behind. He had some epistaxis, about half-past three 
o'clock A.M., which was followed by considerable relief to his sen- 
sations. — Haheat mni ruhri ^vi. — Admoveantur hirudines m ah- 
domini infra umhilieum. R. olei erotonis gtt. iv, extracti colo- 
eynth. compos, gr. xij. Misce, et divide in pilul. iv pares. Haheat 
unam seeundd qudque hord, donee alms soluta fuerit. 

Vespere. The leeches have bled well, and there is still much 
blood oozing from their bites. There is less abdominal tender- 
ness. He is excessively obstinate, and difficult to manage; and 
in consequence of his violence, the nurse has not been able to 
administer the pills. He has had no stool. — Let three drops of 
croton oil he applied to the hack part of the tongue; and if he has 
not a stool vnthin an hour, let him have an enema, with eight drops 



HIGHLY CONGESTIVE FORM. ol 

of croton oil, in about an ounce of gruel, which must he ivell thrown 
up. — Habeat liquoris sodw chlorinatw ^ss; et sumat ex aqua gtt. oox 
Stid qudque hord. 

12th August, {seventh day.) He is much worse ; and is at 
present lying on his back, moaning much. He cannot be roused 
to answer questions ; but he gives indications of feehng pain, 
when pressure is made over the abdomen, which communicates 
the same sensation to the hand as it did yesterday, excepting 
that the skin is cold and clammy, as on other parts of the body ; 
the teeth and mouth generally are encrusted with black sordes ; 
he has had more epistaxis ; the conjunctivae are much yellower 
than yesterday; the bowels have not yet been moved. He began 
the chlorinated solution this morning; and has had more than his 
allowance of six ounces of wine. In accordance with the pre- 
scription of last night, the croton oil was applied to the back 
part of the tongue ; but from negligence, the enema has not been 
administered. — Habeat vini rubri Ix. Applicr. emplastrum wsi- 
catorium toto capiti. — Injic. enema cum olei crotonis gtt. x, et spirit, 
terebinth. Zij statim ; et enema domesticum cum sol. mur. morphiw 
Zss post horam. 

Vespere. At half-past three p.m. the enema was administered, 
but it produced scarcely any evacuation. The bhster was applied 
about 1 P.M. About 2 o'clock, he became much calmer; and 
died, apparently without suffering, at 5 p.m. 

Sectio Cadaveris. — 14ith August, at half-past 1 p.m. 

External Inspection. — Since death, the conjunctivae have become 
more yellow. There are some excoriations on the penis, and 
scrotum, which parts have a bruised appearance. 

Internal Inspection. — Thorax, — The cartilages of the ribs, the 
pleurae, and the subcutaneous cellular tissue, exhibit a deep 
yellow tinge ; in cutting through the cartilages of the ribs, a 
yellow fluid exuded from their centres. The lungs are healthy, 
but much congested with blood posteriorly, as was to be ex- 
pected from the supine position of the patient, previous, and 
subsequent to death. The right lung weighed 1 lb. 6 oz.; the 
left, 1 lb. 1 oz. The bronchial mucous membrane was much red- 
dened and congested. The heart weighed 14 oz.; it was very 
soft, and its internal surface was stained of a dark yellow colour, 



32 



HIGHLY CONGESTIVE FORM. 



by the contained blood and Kserum ; it contained one or two im- 
perfect clots; all the valves were healthy. 

AMomen. — The serous covering of the intestines and abdomi- 
nal walls was deeply tinged with yellow. There were some ad- 
hesions, apparently of old standing, between the gall-bladder and 
intestines. There was no effusion into the abdominal cavity; 
and no injection or redness of the peritonoeum. The mucous 
membrane of the stomach was unusually thick, but apparently 
healthy. The mucous coat of the duodenum was also very thick; 
it had a blackish hue, but was in other respects natural. In the 
colon, there was some black foeculent matter, and its mucous 
membrane, besides having the same black, dyed-like appearance 
seen in the duodenum, exhibited black patches at intervals. In 
these places, the mucous membrane exhibited its natural tena- 
city. By carefully raising up the mucous membrane from the 
black patches, they were distinctly seen to be produced by 
exudation of blood into the submucous cellular tissue. The 
solitary glands were healthy. The internal surface of the 
jejunum and ileum presented the same dark colour as that of the 
duodenum, excepting that it was less deep in hue, and not 
quite general. The liver weighed 4 lb. 15 oz., and was of the 
natural colour and consistence, so far as mere cursory inspection 
and feeling could entitle one to decide. The bile-ducts were 
pervious; and on firmly pressing the gall-bladder, a little bile 
flowed into the duodenum. The gall-bladder was flaccid, and 
contained rather less than the quantity of bile usually found, 
which resembled tar in appearance, was excessively viscid, and 
could be rolled out and suspended for some seconds on the knife, 
as if it were a coherent membrane. The spleen weighed 1 lb. 5i 
oz.; it was firm, much congested, and enlarged; its altered con- 
dition was obviously of long standing. Both kidneys were of a 
yellow colour in all their textures ; the right weighed 8 oz. ; and 
the left 10 oz. The bladder was healthy, and contained some 
ounces of deep golden-coloured urine. 

Head. — The integuments, when cut into, exhibited a deep yellow 
colour; and the cranial bones themselves were decidedly of the 
same hue. The dura mater was of a deep yellow colour. There 
was a small quantity of yellow sub-arachnoid effiision. The late- 



HIGHLY CONGESTIVE FORM. 



33 



ral ventricles contained a drachm of yellow serum, of which there 
was also a little seen at the base of the cranium, when the brain 
was removed. The substance of the brain was firm, and more 
vascular than usual. 

Case VIII. — Summary. — Admitted apparently in articulo mortis 

— jaundice — JicemorrJiage from the rectum.- — Upon Dissection, the 
hile-ducts icere found pervious, the gall-bladder contained tenacious, 
inspissated, tar-like hile; the gastro-intestinal mucous membrane 
exhibited vascularity, and sub-mucous exudation of blood: under 
the endo-cardium, especially in the left ventricle, there was considera- 
ble effusion of blood. 

A. Campbell, a Scotchman, aged 40, married, a shoemaker, re 
siding in Stevenlaw's Close, was 

Admitted, 1 p.m., 25^7^ August, 1843. He lay in a collapsed 
and insensible state. On being roused, in answer to questions, he 
says, that he has no pain; but he can give no account of himself. 
The extremities are quite cold, and the temperature over the 
whole body is much reduced ; the fingers are white, and the nails 
blue; the tongue is moist, and coated with a black paste; there 
is distinct yellowness of the conjunctivse, and surface of the body; 
the face is sunken, haggard, and of a pale lemon colour; he has 
singultus at times; he has haemorrhage from the rectum; the 
pulse at the wrist cannot be felt; there is, on the right side of the 
epigastrium, a raw surface occasioned by the application of a blis- 
ter ; numerous purple spots, as large as peas, are scattered over 
the arms, chest, and abdomen. No friend or relation accom- 
panied him to the hospital; and the nurse has learned that he 
has been removed from home, contrary to the advice of his me- 
dical attendant. 

As soon as he was laid in bed, heat was applied to the feet, 
sinapisms to the calves of the legs, a special watch appointed, and 
spirits and wine ordered to be given as circumstances indicated. 

Quarter to M p.m. Since admission, at 1 p.m., he has taken 
four ounces of whisky, and two ounces of wine ; the extremities, 
but not the trunk, have become much warmer; the pulse is G6, 
intermitting, very small, and feebb; he appears to be slightly re- > 

F 



34 



HIGHLY CONGESTIVE FORM. 



vived, but the singultus continues, being always excited by taking 
fluids, which he swallows, though with difficulty. 

2Qth August^ noon, — He slept quietly during the night; and 
seems to be in much the same state as when reported last night; 
the pulse is, if anything, a little firmer. He has taken, since ad- 
mission, 10 ounces of whisky, and 2 ounces of wine. — Haheat 
esG aqua,, liquoris sodce cJilorinatw gtt. xx^ tertid qudque hard. 
— Continuatur spiritus communis. 

He expired in the evening. 

Whilst we were engaged with the autopsy, Mr Thomas Lee, 
happening to come into the theatre, recognised the body as that 
of a dispensary patient, whom he had attended from the 18th 
of August, up to his admission into the hospital, on the after- 
noon of the 2oth. He afterw^ards had the goodness to send me 
a copy of the memoranda which he kept of the case. As they 
contribute to make the narrative more complete, they are here 
introduced. 

" August 18th. — Fever ? — Muscles well developed and hard ; 
has been subject to rheumatism, and winter cough ; little work, 
and deficient supply of food; some bronchitis. August l^th. — 
Has ringing in the ears, and a good deal of headach; pulse 
100, full, and very firm; has appetite for food. Made to sit 
up in bed, and hold the bowl, whilst he was bled ; about gxvi 
flowed in a full stream ; when the pulse became a little softer, 
the arm was tied up; no sickness was caused, and the only 
apparent effect of the bleeding w^as to make the head a little 
easier. — August 20th. Feels much better; the pulse is 120, full, 
and soft ; pains in the left groin, and right shoulder ; tongue is 
dry, and covered with a white fur ; the bowels have not been 
opened by a colocynth and blue pill taken ; took a herring, with 
bread and coffee this morning. He got up last night, after the 
bleeding, to kindle the fire, and whilst so engaged, fell with his 
head into the grate. — August 21st. Pulse is 112, full, and soft; 
tongue dry and yeflow ; skin cool ; feels comfortable, and thinks 
that he is recovering, but seems a good deal exhausted ; cough 
not troublesome, except on exertion ; no headach, except when 
he coughs; complains of ringing in the left ear; the bowels have 
not yet been moved, although he has taken seven pills composed 



HIGHLY CONGESTIVE FORM. 



35 



of equal parts of the compound colocynth and blue pill mass ; 
his appetite continues; he takes coffee, bread, and gruel. Order- 
ed to take two colocynth and hyoscyamus pills every three hours 
till the bowels are moved. — August 22(^. A great change for 
the worse; he lies in a lethargic state, approaching to coma, 
but can be roused ; the breathing is drowsy ; the voice is almost 
inarticulate ; his tongue seems to be too large for the mouth ; 
complains of weakness of the right leg, but the sensation is 
equal, and natural in both ; he grasps most firmly with the left 
hand ; the bowels have been moved ; the pulse is 100, soft, and 
easily compressed ; some hiccup. Ordered three ounces of wine, 
and a turpentine enema, and if the lethargy continues, a blister 
to the head. — August 2Sd. Did not use any of the remedies 
prescribed yesterday ; and is much in the same state. A good 
many large purple spots have come out on his arms ; the pulse 
is 90, full, soft, and very compressible ; the tongue is covered 
with a clammy, ash-coloured fur; when he breathes, he puffs out 
the left cheek ; some raving ; hiccup ; no stool. Ordered an 
aperient, a blister for four hours to the epigastrium, and some 
wine. — August 24^th. Pulse is 72, and irregular ; the tongue is 
dark, but moist ; the skin, and conjunctivae are yellow ; the 
purple spots have increased in size and number, and are now to 
be seen in abundance, on the arms, chest, back, and abdomen ; 
the stools are loose, and black ; considerable hsemorrhage from 
the bowels last night ; some hiccup at present, but has had none 
since yesterday till now ; speech improved ; has been much im- 
proved by a very little wine. His wife and himself are most 
anxious for his removal to the hospital, against which hazardous 
proceeding I have earnestly dissuaded tliem. ~ August 25th. 
Pulse is 90, weak, and very irregular ; he is very yellow ; the 
speech is almost natural; he passes his stools in bed. Whisky, and 
pills of acetate of lead and opium prescribed. When I returned 
at night, I found that he had been carried off almost naked to 
the hospital." 

Sectio Oadaveris, 28tli August^ 2 p.m. 
External Inspection. — The blistered surface is highly injected 
with blood, and of a yellower and darker colour than the rest of 
the body, except the scrotum, the whole of which is ecchymosed. 
The purple spots are less distinct than during life. 



36 



HIGHLY CONGESTIVE FORM. 



Internal Inspection. — Thorax. — Upon opening the chest, the 
cartilages of the ribs, and the pleurse were observed to be yellow. 
The lungs had the carbonised appearance of what is termed the 
colliers' lung ; they crepitated all over, and were not in any part 
indurated. The left lung, in its upper and middle lobes, was con- 
densed, and a portion of it, when cut into, sunk in water; it 
weighed one pound twelve ounces. The right lung weighed two 
pounds twelve ounces ; and both would have weighed more, had 
the weights been used before the organs were cut into, and 
blood thereby allowed to escape from them. The heart weighed 
twelve ounces, and w^as healthy in structure; its lining membrane 
was reddened, and in some parts, but chiefly in the left ventricle, 
there was much extravasation of blood under it. 

Abdomen. — The peritoneum was observed to be yellow, and in 
some parts injected. The stomach, over one third of its whole 
surface, exhibited a very black colour, from the presence of blood 
effused on the surface of, and under the mucous membrane. 
The colon was a good deal injected in various places; and in 
it, and other parts of the intestinal canal, were black spots 
caused by the exudation of altered blood. The rectum was in- 
tensely injected; there was sub-mucous effusion of blood in it, 
and a good deal of black altered and loose blood was lying on 
the mucous membrane : this appearance in the rectum was very 
similar in kind to that found in the stomach. The bile-ducts 
were pervious; and the duodenum was stained with bile, and di- 
versified with black patches, caused by the effusion of blood upon, 
and under the mucous membrane. The gall-bladder was full, 
but not distended ; its contents were inspissated bile, like tar, 
but more glistening, which, when raised on the back of the dis- 
secting-knife, hung down tenaciously in a membranous-looking 
mass. The liver was softer than natural; and when cut into, the 
section exhibited a dingy lightish colour. The spleen weighed 8 
ounces, and broke down readily under the fingers. The blood- 
vessels of the mesentery were highly injected. A section of the 
kidneys displayed slight yellowness; they were much injected, 
especially around the bodies of Malpighi; the right weiglied eight 
ounces, and the left seven ounces. 

Head. — Upon removing the scalp, the same yellow colour which 
was seen in the cartilages of the ribs, pleura}, and peritoneum, 



HIGHLY CONGESTIVE FORM. 



87 



was observed in the cellular tissue, and bones when sawn through. 
The dura mater was yellow, and the arachnoid much injected. 
A section of the upper lobes of the brain did not exhibit more 
than the usual number of red points. Two drachms of fluid 
were removed by the pipette from the left, and three drachms 
from the right ventricle ; it was of a muddy, and yellow colour. 
There was half an ounce of bloody serum found at the base of 
the brain. Upon stripping off the arachnoid from the convolu- 
tions, there were observed upon them, all over the cerebral mass, 
numerous pultaceous spots, with some rosy specks. The cere- 
brum weighed two pounds twelve and a half ounces; the cerebel- 
lum, pons Varolii, and medulla oblongata, six and a half ounces. 

Case IX. — Summary. — Admitted on the 11th day^ during the 
Intermission — Relapsed on the 12th day — haemorrhage from the 
vagina — yellowness— dyspnoea — sudden Death on the 14<th day. 
On Dissection, the gall-bladder was found to contain hile, and the 
ducts to he pervious. 

Jane Merrilees, aged 39, servant in a Clyde Street brothel, was 
Admitted Qth October, {eleventh day^ It appears, that her pre- 
sent illness commenced with rigors on the 26th September, two 
days after which, her mistress, suspecting that it was the prevail- 
ing fever, dismissed her. She then went to lodgings in the Grass- 
market, where she has been till now. She admits, that for years 
past, she has been addicted to habits of extreme intemperance. 
Some months ago, she had an attack of hemiplegia, from the 
effects of which she has considerably recovered. She is very weak, 
and either unable or unwilling to give any account of the progress 
of her case since the invasion of the rigors. She says, that she is 
better to-day than she has yet been, and has been slowly improv- 
ing during the last three or four days. The pulse is 100, and 
small ; the tongue is clean, dry, but not parched ; the bowels are 
open ; her chief complaints are of debility, and sleeplessness. She 
is much disturbed with the fear of death. — Habeat hord somni 
solutionis muriatis morphiw Zss, forma haustus. — Habeat spiritus 
communis f)iv, forma " toddy.'''' 

Sth October, (thirteenth day.) She got the morphia draught at 
10 P.M., but has slept none, and feels worse to-day. She is 



38 



HIGHLY CON'GESTIYE FORM. 



troubled with urgent fits of dyspnoea, some diarrhoea, and pain of 
the abdomen. The tongue is brown, and moist ; the pulse is 96, 
weak, and small ; there is no headach ; there is profuse hsemor- 
rhage from the vagina; she states, that the menses appeared, and 
disappeared naturally, a fortnight ago. The skin has become 
yellow. — It. misturce cretce §'y^, tincturw opii 7>i. Misce: Sumat 5* 
post singulam liquidam dejectionem. — H. alcoholis ammoniatw Zi. 
Sumat gtt. urgente dyspnoea. — Haheat^ Jiord somni, enema amyli 
cum solutionis muriatis morpJiiceZi. — Continuatur spiritus communis. 

^tJi Octoher^ {fourteenth day.) During yesterday afternoon, the 
yellowness increased somewhat, but she seemed as well as at the 
forenoon visit. In the evening, she had some delirium. The 
ammoniated alcohol, which had relieved the dyspnoea consider- 
ably, being finished, a tea-spoonful of the tincture of valerian, be- 
longing to a neighbouring patient, w^as given about 4 p.m. to allay 
an alarming paroxysm of dyspnoea, and it apparently did so. 
She complained much in the evening of a sense of suffocation, and 
with difficulty swallowed her toddy. Ten minutes before her death 
she was pretty well, and entered into coherent conversation with 
the nurse upon indifferent topics. She died at half-past three 
this morning, during a paroxysm of dyspnoea. 

Seotio Cadaveris, lO^A October^ 2 p.m. 

Externallnspection. — The body, which was found plump and fat, 
did not exhibit the yellowness more distinctly than during life. 
There was great lividity of the countenance, and of the anterior 
part of the body, as far down as the clavicle; livid patches were 
also seen all over the body. 

Internal Inspection. — Thorax. — Both lungs were healthy. The 
right lung w^eighed one pound two ounces ; and the left fourteen 
ounces. The heart weighed ten and a half ounces, and svas natu- 
ral as to size, and firmness of texture. On dividing the great 
veins at the root of the neck, a large quantity of very fluid, and 
very black blood escaped. 

Abdomen. — On the inferior part of the anterior surface of the 
liver, two large white patches of thick and dense lymph were 
observed: the organ itself had a nutmeg appearance, was very 
dense, and -weighed five pounds eight ounces. The gall-bladder 
was filled, but not distended with bile. The spleen was greatly 
enlarged, very soft, and weighed one pound seven ounces. The 



HIGHLY CONGESTED FORM. 



39 



splenic, mesenteric, and portal veins were full of fluid blood. The 
duodenum was congested ; the other intestines were not exa- 
mined, circumstances having abruptly terminated the autopsy. 
The uterus was intensely congested, externally and internally. 
There was much ovarian and uterine disease. 

Head. — The brain was unfortunately examined only in a hasty 
and cursory manner; nothing abnormal was seen, except un- 
usual vascularity of the arachnoid. 

Case X. — Summary. — Epistaxis on the 6th, yellowness on the 7th, 
symptoms of delirium tremens on the ^th, purple spots on the 11th; 
and sudden Death on the IZth day. Treatment; stimulants, with 
calomel and opium. — No Autopsy. 

William Brunton, house-painter, a native of Edinburgh, and 
resident in it from his birth, at present living in Blackfriars 
Wynd, aged 32, single, robust, with dark hair and eyes, was 

Admitted, 1st October 1843, fifth day). He states, that he is 
much addicted to habits of intemperance, that during the last 
three months he has had no employment, and very scanty aliment. 

He was seized, on the afternoon of the 27th September, with 
rigors, which continued, with a general feeling of cold, till the even- 
ing, when he went to bed, and sweated profusely, without any re- 
lief to the headach and general soreness, with both of which he 
was oppressed from the commencement of the rigors. On the 
night of the 29th, he again sweated a good deal, without any relief. 
On the 30th, he had, for the first time, general pains, especially 
in the joints, and prostration of strength. He has never been 
entirely confined to bed, until admission into the hospital, and 
yesterday, he was in the streets all day. He is not aware of hav- 
ing been exposed to contagion. 

The expression seems to be natural, exhibiting perhaps slight 
depression; the countenance is florid, and in no degree either 
purple or bronzed; the pulse is 112, "full, bounding, and not 
very easily compressed; the tongue is moist, and coated with a 
white fur; the bowels are open; the headach slight, except when 
he coughs; the intellect is clear; the muscular power is much de- 
pressed. He complains of want of sleep, and some cough at night, 
a slightly vitiated taste, and general pains. The conjunctivae are 



40 



HIGHLY CONGESTIVE FORM. 



much injected, his voice is hoarse, and his throat a good deal 
inflamed. — Let the throat he enveloped in a hot wet doth^ external to 
tohich let another dry one he applied; let hoth remain on for twenty- 
four hours. — Haheat troch. ipecacuanhce et morphioe Ix. 8ig. To he 
he used when the cough is trouhlesome. 

2d Octoher, (sixth day). He feels, and looks in every respect 
better. The florid appearance of the countenance is less intense, 
but there is no decided bronzing as yet. The hoarseness, and un- 
easiness in the throat speedily ceased after the applications ordered 
had been made; and he now feels his throat perfectly cured. Upon 
examination, it appears, that the inflammation does not now exist. 
He slept pretty well during the night, being little troubled by 
cough, which indeed has not annoyed him much since he began 
to use the lozenges. About seven this morning, epistaxis began, 
and continued till now, (half-past 11 a.m.), when it seems to have 
ceased; some relief has followed the epistaxis. He states, that, 
when in health, he is subject to epistaxis, but that he never had 
it to the same extent, as on the present occasion. The tongue 
is moist, and not more coated than yesterday; the bowels have 
not been opened since admission; the pulse is 98, and of natural 
strength. — Haheat enema purgans. 

Sd Octoher, (seventh day.) The enema operated freely, and gave 
relief. The respirations are 86 in the minute; the pulse is 
112, and of moderate strength; the tongue is moist, and coated 
with a yellow fur. There is a yellow, or saffron colour, of con- 
siderable intensity, pervading the forehead, face, chest, and abdo- 
men; it extends to the knees, where it all at once greatly di- 
minishes in intensity, and upon the legs is faint, and on the feet 
invisible; upon the arms and forearms, it is more distinct than 
on the legs, but less so than on the chest and abdomen; upon 
the hands it can be seen, but is there exceedingly faint. — Haheat 
pil. calomel, et opii vi. Sumat unam quartd quaque hora. — Haheat 
spiritus communis ^vi. Sumat semiunciam secundd quaque hord, 
forma " toddy T 

Uh Octoher, (eighth day). He rested pretty well during the 
night ; the intensity of the yellowness has greatly diminished ; 
the respirations are 26 in the minute; the pulse is 92, and of 
good strength; he has taken six ounces of the whisky in toddy, 
and three of the pills, as directed; the urine is scanty, and in 



HIGHLY CONGESTIVE FORM. 



41 



appearance resembles muddy porter ; he has had occasional fits 
of delirium, with some violence; at present, he is incoherent, and 
since this report was commenced, he has made several attempts 
to get out of bed. He has a good deal of tremor, restlessness, 
and subsultus tendinum. He keeps up an almost incessant con- 
versation, in a low muttering tone, with individuals by whom he 
imagines himself surrounded. 

5tJi October^ {ninth day?) He has more restlessness, subsultus 
tendinum, and delirium; and has slept none since yesterday; the 
yellowness is somewhat less distinct ; he has, at present, slight 
recurrence of the epistaxis. From neglect on the part of the 
nurse, he has only had one more of the pills since yesterday; 
that is to say, in all he has only had four of the calomel and 
opium pills. — A calomel and opium pill has just heen administer- 
ed. — Haheat pilulam calomelanos et opii, tertia qudque hora. 

%th Octoher^ {tenth day.) Soon after the visit yesterday at 
noon, he fell asleep, and slept till midnight, when he awoke, 
feeling much better. At present, he is lying upon his back, 
slumbering and moaning; the pulse is 86, firmer, and quite re- 
gular; the tongue is moist, excepting in the centre, where there 
is a brown and parched longitudinal streak; he complains much 
of thirst; since yesterday, he has had three black stools; the 
urine has the same appearance as when last reported; the yel- 
lowness is slowly going off"; there is very little incoherence, and 
less subsultus tendinum. — Let him ham no more of the calomel and 
opium pills till ten this evening, when he is to get another. 

Vesper e. He has had the pill. He remains much as he was 
at the noon visit, except that the pulse is decidedly weaker. — R. 
mist, camphorw ^iss, sol. mur. morphiw Ziij. Misce. Sumat Zss 
secundd qudque hord, donee dormiat. — Continuatur ''^ toddy.''"' 

7th October, (eleventh day.) He slept none during the night; 
has had no violence, but incessant low muttering delirium, with 
subsultus tendinum; and this is the state in which he lies at pre- 
sent. The yellowness has not diminished since yesterday; and 
fi'om there being less of the purple in his cheek, it is more strik- 
ing to-day; the stools have greatly lost the pitchy appearance of 
yesterday, but are still very dark- coloured; the pulse is 88, weak 
and tremulous; the respirations are 25 in the minute; the dia- 
phragm descends freely; the tongue is parched, and stiff. On the 

G 



42 



HIGHLY CONGESTIVE FORM. 



chest and abdomen, there are some purple, irregularly formed, and 
sparsely scattered, spots. The nurse states, that there is a white 
sediment in the bottom of his urine; the urine itself is now of a 
brown colour. He has had seven ounces of whisky since the noon 
visit yesterday ; he began taking the camphor and morphia mix- 
ture at 10 P.M., and has had three doses of it. — To resume the 
calomel and opium pills, takina one every four hours, till noon visit 
to-morroiu. — Increase the whisJcy to ten ounces. — Omit the mixture 
of camphor and morphia. 

10 P.M. He is much in the same state as at noon. The pulse 
is of good strength. — Continue the whisky, and the pills. — To have 
a Mister applied to the head for three hours. 

8th October, (ttvelfth day.) He continued during the night as 
when seen at 10 p.m. The bowels have been opened this morn- 
ing once, and the same pitchy-looking matter passed as for- 
merly; the pulse is 108, weaker than at the visit last night; the 
pupils are contracted; he lies on his back in a slumbering state, 
moaning, and making a gurgling noise in the throat. — Omit, pi- 
lules. — Contin. spiritus communis. 

^th October, {thirteenth day.) He continued in the same 
state during the night, with the addition of more restlessness. 
He rose unassisted three times to stool, which ought not to have 
been, and which is, in such cases, alwaj^s forbidden; at each time, 
he had a black stool, the last, however, being not so dark as the 
two former. He got his spirits regularly. The last time that he 
rose was at five minutes to six this morning, when he got up with 
as much activity as on the previous occasions; he had scarcely 
been put to bed, when he expired. He died at 6 a.m. Had 
this man been properly watched by the nurse, death would not 
have taken place so early, and in the manner in which it occurred. 

An autopsy was refused by the relations, which is much to be 
regretted. 

Case XL — Summary. — Admitted on the 9th day, during a remis- 
sion — yellowness on the eleventh day — black altered blood issuing 
from the rectum — Treatment; stimulants, and blue pill — Death on 
the nineteenth day; no autopsy. 

David Matheson, residing in Stockbridge, aged 57, married, 



HIGHLY CONGESTIVE FORM. 



43 



with brownish grey hair, blue eyes, by occupation a gardener, 
born in Edinburgh, where he has always lived, was 

Admitted 1th October 1848, {ninth day.) — He states, that for 
some time past, he has been in poor circumstances, subsisting up- 
on precarious means. He is not aware of having been exposed 
to contagion. 

On the 29th September, he was seized with rigors, headach, 
severe pains in the back and limbs, and a feeling of great lassi- 
tude. He afterwards became hot, but did not sweat any till 
the night of the 5th October {seventh day)., when he perspired 
profusely, and has felt considerably better ever since. He was 
easier to-day than he has been since the invasion of the disorder, 
but the removal from home has greatly fatigued him; and unfor- 
tunately, to add to his exhaustion, he was made to walk down to 
this hospital from the Infirmary waiting-room, in place of being 
conveyed in a chair. 

The countenance is deeply depressed and purple; the pulse is 
of tolerable strength, the tongue is dry and rather brown, the 
bowels are open, the intellect is clear, and his only complaints'are 
of debility, slight headach, and sleeplessness at night. — Quiescat, 

8th October, {tenth day). — He slept a little during the night; 
the bowels are open; the pulse is 108, and of good strength; the 
tongue has become moist, and assumed a dirty white fur; he has 
frequent short dry cough, but no pain in the chest; he makes 
no complaint. 

9th October, {eleventh day). — Yesterday afternoon, he was ob- 
served by Mr Reid to have a slightly yellow aspect. At present, 
the neck, chest, and part of the face, have a deep saffron colour ; 
in the countenance, the deep purple and yellow colours struggle 
for the mastery; the forehead is yellow, the upper parts of the 
cheeks are purple, and around the mouth, and on the chin, the 
colour is saffron; these colours do not gradually pass into one 
another, except at one or two points, but stop abruptly, form- 
ing a striking contrast; there is no yellowness of the sclerotics, 
and superior or inferior extremities; the tinge on the chest, back, 
and abdomen is just sufficient to be detected. He slept a good 
deal during the night, but moaned much, as if in pain; at present, 
he is easy ; the pulse is 96, and rather weaker than yesterday; 
the tongue is brown and moist; the bowels are confined. — 



44 



HIGHLY CONGESTIVE FORM. 



Haheat vini rubri f^iv^ forma "■negus.'''' — Injiciatur enema domesticum 
statim. 

10th October, (twelfth day^ — He raved and moaned a great 
deal during the night, but this morning makes no complaint; 
the countenance has become much more collapsed, and now ex- 
hibits much more of the purple than of the yellow; on the other 
parts of the body, the yellowness is much deeper than yesterday. 
Upon contrasting the degree of vividness of the yellow in dif- 
ferent parts of the body, it appears to be most intense around 
the lips, eyes, and ears, and on the neck, down to the clavicles ; 
it exists in a slightly less degree on the chest, arms, abdomen, 
and thighs ; beyond the knees and elbows, it is very faint ; it is a 
shade deeper on the fore-arms, than on the legs ; the yellowness of 
the conjunctivse has become very marked. The pulse is 96, full, 
and not very compressible ; the tongue is stiff, parched, slightly 
coated, and of a rusty brown colour ; the bowels have not been 
opened since the evening of the 8th ; he complains much of thirst, 
and pains through the whole body, but especially in the shoulders 
and knees. — Sumat statim pilulas hydrargyri ij; et ms'pere, 
enema cum olei ricini "^ij. — For drink, to have cold beef tea. — 
Vinum ad g-y/, 5 viceiv. 

11th October, (thirteenth day.) — A good deal of black matter 
was evacuated by the assistance of the enema ; the countenance 
is still more depressed than yesterday; the pulse is 76, and 
feeble; the yellowness continues the same; he slumbers con- 
stantly, but is easily roused to answer questions, which he does 
quite rationally, though during his sleep or slumber he has some 
muttering delirium ; he has a strong harsh voice, which he fre- 
quently exerts in calling upon the nurse to give him his hourly 
dose of negus. He refuses to take the beef tea, and will admit 
nothing but the negus within his lips. — A blue jpill has just been 
administered with some difficulty. — Omittatur vinum; et habeat 
spiritus communis ^viij, forma toddy T 

Vespere. — He looks worse, and has passed several semi-liquid 
black stools in bed ; most of his urine during the last two days 
has been passed in bed, but a little collected since the visit in 
a urinal, and now under observation, has the same porter colour 
which has been met with in most of the yellow cases. 

12th October, (fourteenth day.) — The countenance has im- 



HIGHLY CONGESTIVE FORM, 



45 



proved; the pulse is stronger; and the yellowness much diminish- 
ed. — Continuatur spiritus communis, forma '''' toddy ^ 

13^A October, {fifteenth day?) — The countenance is more deject- 
ed; he has had a good deal of disturbed sleep since yesterday; the 
pulse is 88, and of the same strength as yesterday; the yellowness 
has entirely left every part of the body, excepting small spaces 
around the eyes and ears; both cheeks are deeply purple; he has 
had no stool since the 11th; he passes his urine in bed. During 
the last twenty-four hours, he has taken eight ounces of whisky, 
in the form of hot toddy, and also a good deal of beef tea, both 
cold and hot. — Two hlue pills are now administered, being the first 
medicine of any kind which he has taken since the lUh. 

lUh October, {sixteenth day?) — In appearance and strength, he 
seems to be very much as yesterday. He passes his urine and 
stools in bed. On examining the latter, they appear to consist 
entirely of altered blood, and are identical in appearance with 
the black vomit in the case of James Law. He will not speak, 
except to call for his toddy, which he does frequently, and strong- 
ly. In general, he Hes upon his back, moaning much; and 
when any attempt is made to move him he roars loudly, as if 
suffering from muscular and articular pains. — Haheat spiritus 
communis 5^, vice ^mij. 

15th October, {seventeenth day.) — The symptoms continue much 
as yesterday, but he is certainly worse. He has raved none for 
forty-eight hours, and slumbered much. The whole of his whisky 
has been administered. — Continuatur spiritus communis. 

16th October, {eighteenth day.) The matter formerly described 
as similar to the black vomit, seems to be constantly running 
involuntarily from the rectum; the quantity passed is very great. 
He is rapidly sinking; the pulse is small, intermittent, and about 
100, as nearly as it can be counted. The extremities are warm. 
— Continuatur spiritus communis. 

1 7th October, {nineteenth day.) Since the foregoing report was 
made yesterday at noon, he continued to sink till 10 a.m. to-day, 
when he died. Till the time of his death the black matter con- 
tinued to issue in abundance from the rectum. 

The relatives refused to permit an autopsy, which cannot be 
sufficiently regretted. 



46 



HIGHLY CONGESTIVE FORM. 



Case XII. — Summary. — The fever masking phthisis. — Purple 
countenance. — Death from diarrhoea on the 24:th day. — On Dissec- 
tion there ivas found disease of the lungs, ulceration of the lowels, 
and hlack patches on the rectum. 

Mrs Morris, aged 45, (but more like 65,) residing in Morrison's 
Close, thin, pale, and of phthisical appearance, was 

Admitted Tlst September 1843, {sixth day.) She states, that 
her general health is bad, that she occasionally drinks too much 
whisky, that she has had seven children, and three abortions. 
The epidemic fever is in her family. 

She took ill on the 16th September, but cannot give a distinct 
account of the order in which the symptoms appeared; but says, 
that during the first twenty-four hours she suffered from headach, 
general pains, nausea, great debility, intense thirst, and sleepless- 
ness. She got an aperient from a dispensary pupil. 

There is much bronzing. She has felt rather better during this, 
than during the preceding five days. The pulse is 120, and rather 
feeble ; the tongue is coated with a faintly yellowish fur ; she has 
much thirst ; and has had diarrhoea during the last three days ; 
there is no eruption on the skin ; she has much headach ; the 
intellect is clear ; and her chief complaints are of abdominal, 
muscular, and articular pain, deafness, and debility ; there is no 
cough; the abdominal pain is general, and from its being re- 
lieved by firm pressure, may probably to some extent be muscu- 
lar. A very distinct Turner's line extends from the ensiform 
cartilage to the pubis. Her last child was born nine years ago. 
The catamenia ceased two years ago, since which time she has had 
leucorrhoea ; this has been more profuse than ordinary for the last 
three or four days. — R. misturce cretce Ivi, tincturw opii Zi. 
Misce. Sumat li post singulam liquidam dejectionem. — R. acetatis 
plmnbi '^ij, pulveris opii gr. iv, aquw zviij. Fiatlotio: Utatur 
tepidd ter in die 

22d September, 4 p.m., (seventh day.) The pulse is 150, and 
very full ; she is bathed in perspiration ; she was not sweating 
when seen at 10 p.m.; the diarrhoea is gone, and she is very 
feeble. — JIabeat vinum ad '%iij, forma " nequs^'' 



HIGHLY CONGESTIVE FORM. 



47 



9 P.M. She has had the wine at intervals, to the extent of 
three ounces. The pulse is 96, and very compressible ; the ex- 
pression is very depressed; the skin is covered with a cold clammy 
perspiration ; the tongue is moist, and black, as if smeared with 
black currant jelly ; there is much thirst ; and great deafness. — 
Continuatur vinum. 

2Sd September, 9 p.m., (eighth day?) Being asleep, she was pass- 
ed at the noon visit. She has dozed a good deal during the day, 
and is considerably less depressed in countenance than yesterday; 
the pulse is 66, of better strength, but still very feeble; the tongue 
is as yesterday; the skin is cool and dry; the bowels have been 
opened twice, the evacuations being formed, and feculent. — Gonti- 
nuatur vinum. 

2ith September, half-past 2 p.m., {ninth day.) She has had a 
good night; the countenance is improved; the pulse is 78, and 
of better strength; there has been one stool; the bronzing is now 
very apparent. — Continuatur vinum. 

25th September, (tenth day.) There is some slight improve- 
ment since yesterday. — Continuatur vinum. 

21th September, {twelfth day.) For two days past, she has 
been improving, sleeping well during the night, and slumbering 
a good deal during the day. She has neither sweatings, diarrhoea, 
nor cough. — Continuatur vinum. 

2^th September, {thirteenth day.) She is still improving, but 
was much disturbed with cough and dyspnoea during last night; 
the bowels are confined. — Admoveatur statim sinapisma pectori. 
— Sumat trochiseas ipecacuanhce et morphias urgente tussi. — 
Habeat, hord somni, solutionis muriatis morphias gtt. xxx, forma 
haustus. 

29th September, {fourteenth day.) She makes no complaint, 
and is gaining strength rapidly. — Continuatur vinum ad ^iv, vice 
6viij. 

2d October, {seventeenth day.) She continued improving till 
last night, when she was seized with slight rigors, and sudden loss 
of the strength which she had regained. The bowels are open; 
the countenance is purple. — Habeat vini rubri oviij. 

Zd October, {eighteenth day.) She slept well, but the counte- 
nance is more purple, and depressed than yesterday ; the pulse is 



48 



HIGHLY CONGESTIVE FORM. 



124, small, and thready; the tongue is clean, and moist; the 
bowels are rather loose; she has a good deal of cough, with co- 
pious expectoration of white frothy mucus. — Continmtur mnum. 
— Haheat^ liora somni^ enema mnyli^ cum solutionis muriatis mor- 
pMoB 7)1. 

4:th October^ {nineteenth day.) The general appearance is ra- 
ther improved; though the diarrhosa has returned, and the pulse 
continues extremely feeble; the tongue is clean and moist. The 
enema was administered last night. — Surmt tincturoe opii gtt. xv, 
quartd qudque liora ad tertiam mcem. 

Dtli October, {twentieth day.) She has had three doses of the 
laudanum, and no return of the diarrhoea. She says, that she 
feels much better, and the countenance is certainly improved, 
but it is to be feared, that the apparent amendment is the tem- 
porary effect of the laudanum. — Qwiescat. 

7th October, {twenty-second day.) — The diarrhoea has returned. 
— Suniat decocti hematoxyli tertid qudque hord. 

8th October, noon, {twenty-third day.) — Three doses of the de- 
coction of logwood have been taken, and a starch enema with 
sixty drops of laudanum administered, with very little relief to 
the diarrhoea. The countenance is much depressed ; and the pulse 
is small and weak. 

9th October, {twenty-fourth day.) — Since the visit at noon yes- 
terday, she had only one scantj^ black stool. She continued, 
nevertheless, to sink, and died this morning, at half past 12 
o'clock, having retained to the last her consciousness of ap- 
proaching dissolution. 

Sectio Cadaveris. — 10th October, 3 p.m. 

External inspection, — The countenance has a blue, shrunk ap- 
pearance, and on various parts of the body are livid patches. 
Turner's line is not quite so distinct as during life. A portion 
of the integument, in the situation of the Hue, having been re- 
moved, was subjected to a microscopic examination by Professor 
Allen Thomson, who could discover nothing except a staining of 
the cuticle. 

Internal inspection. — Ttiorax. — The right lung adhered firmly 
throughout, to the costal pleura, contained tubercles in various 
stages, and in the upper part of the left lobe, a large abscess; 



HIGHLY CONGESTIVE FORM. 



49 



it weighed one and a half pounds. The left lung is also firmly, 
but less extensively adherent to the costal pleura ; it is much 
healthier than the right, and the few tubercles which it contains 
in the upper part, are in an early stage ; its weight is one lb. one 
oz. The heart is soft, and flabby ; its weight is seven oz. All 
the vessels in the chest and neck poured forth an unusually large 
quantity of fluid blood, when cut into. 

Abdomen. — The gall-bladder is full of black, inspissated, and 
very tenacious bile. There is bile, and feculent matter in the in- 
testines. The liver, with the gall-bladder and its contents, 
weighed three pounds nine ounces. The small intestines were 
highly injected, but upon a careful scrutiny, no ulcers could be 
detected on the mucous coat. On the raucous lining of the 
transverse arch of the colon, there is an ulcer, of the size of a 
kidney bean, and two others, as large as split peas. There were 
no ulcers in the rectum, but several black patches, which owed 
their colour in part to the matter contained in this bowel, 
and also, to the sub-mucous exudation of blood. The black 
matter was apparently altered blood. 

Case XIII. — Summary. — Admitted on the twelfth day^ during a re- 
mission — Appearance of yellowness on the eighteenth day — Dea th 
on the tv)enty-third day. No autopsy. 

Michael Dowlands, coachraaker, aged 42, married, resident in 
Edinburgh for the last twelve years, and now living in the Grass- 
market, of ordinary development, with brown hair, and blue 
eyes, was 

Admitted^ 1th October^ (twelfth day.) On the 26th of Septem- 
ber, he was seized with shivering, headach, and pain in the neck. 
He has had no pain in the back; he vomited some, from medi- 
cines taken by the advice of a dispensary pupil ; the bowels have 
been kept open by aperient drugs. He states, that he has not 
had regular work, but upon the whole, a sufficient supply of food. 

His expression is natural ; the pulse is of good strength ; the 
tongue is clean ; there is a good deal of thirst ; the bowels are 
open ; there is no eruption of any kind on the body; the headach 
is pretty severe; he has a bad taste in the mouth ; the muscular 
power is very weak ; and the general pains arc very severe. Ho 

II 



50 



HIGHLY CONGESTIVE FOllM. 



states, that he feels much better now, than he was some days 
ago. — Quiescat. 

9th October, (fourteenth da^/.) He slept pretty well during last 
night, and feels better; the bowels are opened; the pulse is 108, 
of good strength; the skin is hot, and dry; he complains of mus- 
cular pains in the abdomen on breathing; also, of pains in the 
limbs. — B. sulph. quinince infusi gentiancB liv. Misce. Sumat 
seoctd qudque hord. 

11th October , {sixteenth da^.) Since last night, he has had 
some diarrhoea ; nevertheless, he is improving in other respects. 

— It. misturce cretw lij\ tincturw opii camphoratw Zj- Misce. Statim 
smnat. 

l^th October, {seventeenth day.) The bowels are natural; he 
slept well ; and continues improving. 

IZth October, {eighteenth day.) His tongue is moist, and 
slightly coated with a yellow fur ; the pulse, and skin are natu- 
ral ; he has some headach ; there is a slight return of the diar- 
rhoea. Since yesterday, slight yellowness has appeared in the 
countenance, and at present, covers it, and the anterior part of 
the neck, extending as low down as the clavicle. — Repetatur mis- 
tura cretw, cum tincturd opii. — Omittatur mistura quinince. 

Ibth October, noon, {twentieth day.) In consequence of the 
depressed state, in which he was found yesterday at noon, six 
ounces of whisky were ordered, all of which has been taken in 
the form of toddy. During the last few days, he has certainly 
lost ground. The pulse is 100, full, and easily compressed ; the 
respirations are 34 ; he has pain in the chest, and some loose 
cough ; the yellowness is less intense ; he changes colour fre- 
quently, and suddenly; he has pain in every part of the body. — 
Habeat enema amyli, cum solutionis muriatis morphice ^i, hord somni. 
— Applicetur msicatorium pectori 4x5. 

1 Qth October, {twenty-first day.) There is some slight improve- 
ment in every respect, although he has had no sleep since yester- 
day. — Continuatur spiritus communis. — Habeat, hord somni, solu- 
tionis muriatis morphias gtt. oosox, formd haustus. 

Vlth October, {twenty-second day.) His appearance is rather 
better than yesterday; he had several short sleeps during the 
night ; he refused the draught ; ho raves a little at intervals, but 
at present, answers questions rationally; the bowels are loose; 



HIGHLY CONGESTIVE FORM. 



51 



lie has taken several doses of chalk mixture. — Continuentur mis- 
tura cretw^ et spiriUis communis. 

18th October, (twenty-third da^.) Yesterday, at five o'clock p.m., 
he was to all appearance as at noon, slowly mending, and took 
some panada, along with his toddy. At midnight, he became rest- 
less, and raved a good deal. In this state, he continued till five 
this morning, when he ceased speaking, and died shortly after- 
wards, having gradually become comatose. 

Case XIV. — Summary. — Yellowness; pain, and dulness over the 
liver. — A mild Relapse on the 15th day. — Restoration to health. 

William Robinson, aged 85, a native of Edinburgh, unmar- 
ried, by trade a smith, in partial employment during the last few 
months, often pinched for food, and occasionally intemperate, was 

Admitted, 12th September, (fourth day.) He is of spare, 
but strong make; has black hair, dark eyes, and a sallow com- 
plexion. He has been lately living in Richmond Street, in a stair 
where there is much fever. He had fever in Queensberry House 
Hospital some years ago. 

He took ill on the 9th, with severe headach, and pains in 
the back and legs, some sweating, a good deal of cough, much 
thirst, but no rigors. Since then, he has slept little. 

On admission, he is found to have severe headach, gene 
ral pains, much thirst, a white moist tongue, and a hot, dry 
skin; the bowels have been twice opened by medicine taken last 
night; the pulse is 132, and soft; he has a good deal of cough, 
with expectoration; and is very deaf. — Applicentur hirudines viii 
temporibus. — Habeat pulveres effervescentes. 

ISth September, (fifth day.) The leeches bled well, but with- 
out relief to the headach. He has some abdominal tenderness. 
— Abradatur capillitium, et applicetur aqua frigida toto capiti. — 
A dmoveantur hirudines viii epigastrio.— Habeat olei ricini ^i, etsol. 
mur. morphias Zss, forma haustus. 

l^th September, {sixth day.) He slept pretty well during the night. 
Since the head was shaved, the headach has been less severe. The 
bowels are open; the tongue is dry in the centre, and moist along 
the sides ; he has much thirst ; the pulse is 88, of good strength ; 
the cough and expectoration continue; there is considerable 



52 



HIGHLY CONGESTIVE FORM. 



lachrymation ; he complains of pain in the region of the Hver; 
there is distinct yellowness of the sclerotics, and skin of the neck 
and abdomen. — Quiescat. 

15th September^ {seventh day.) The yellowness has become 
much more decided since yesterday; the whole surface of the 
body has now a golden aspect, excepting below the knees, where 
the tinge is much less distinct; the yellowness of the sclerotics 
is very deep; the pupils are contracted; and the eyes are suffused. 
This morning, about ten o'clock, in consequence of urgent com- 
plaint of pain in the region of the liver, and pit of the stomach, 
ten leeches were applied, which bled well, and have afforded great 
relief. There is still, however, much pain, caused by pressure 
over a space of some inches in extent, between the mesial line 
and the cartilages of the false ribs on the right side, as well as 
a general soreness on pressure over the whole region of the liver. 
There is no pain or fulness in the region of the spleen. The 
urine is high-coloured. The bowels have been opened four times; 
the evacuations are black, fluid, scanty, and foetid. The tongue is 
covered with a tenacious yellow fur; there is much thirst. The 
skin is soft, and of natural temperature. He has a short tickling 
cough, unaccompanied by any pain in the chest, but which aggra- 
vates the abdominal pain and headach, by shaking the body. 
The pulse is 60, full, and compressible. — To ham the head diligent- 
ly kept cool^ hy a lotion of the muriate of ammonia : and the aMomen 
to he fomented. — Injiciatur enema domesticum. — Haheat vomitum 
sulphatis zinci gr. xii, ex aquce tepidm f)mij^ statim. Haheat vini 
ruhri liv; to have two ounces made into negus, immediately after 
the operation of the emetic; and the remainder at sleeping-time. 

9 P.M. There was copious vomiting of green and brown mat- 
ter from the emetic; and he says, that he has felt much better 
since. The yellowness seems to be less distinct; but, from the 
imperfect light, it is impossible to be certain on this point. The 
abdominal pain has almost entirely left him. The pulse is 118, and 
feeble ; some hours ago, it was not more frequent than at the 
noon visit. He did not get the negus till now. — Ht.pil. calomel, et 
opii unam statim, et repet. eras mane. — Ht. haust. c. sol. mur. morphice 
gtt. XXX, h. s. — Injic. enema amyli c. sol. mur. morph. gtt. xxv, eras 
mane. 

16th Sep)teml)er, {eighth day.) He feels better, and is much iin- 



HIGHLY CONGESTIVE FORM. 



53 



proved in appearance since yesterday forenoon. He got the medi- 
cines which were ordered yesterday ; but has slept none. The 
yellowness of the countenance is less intense, but remains as vivid 
as formerly, on the other parts of the body. One of the leech- 
bites has continued bleeding, and part of his bed-clothes and bed- 
ding are soaked with blood from it. It has now been checked by 
the application of the nitrate of silver, and the pressure of adhesive 
plaster. The abdominal pain has almost entirely left him. He 
had one scanty stool this morning. The pulse is 78, and much 
improved in strength. The tongue is coated with a yellow paste 
in the centre, but is cleaning at the sides. He has had slight 
epistaxis for the last eight hours, which seems now to have 
ceased. He has had five ounces of wine as negus, since yester- 
day. — Continuatur mnum ad '^vi. — Continuentur pilules calomela- 
nos. Haheat Jiaustum cum sol. mm. morpJiiw hord somni. 

7 P.M. He feels better than at the noon visit. The leech- 
bite, which was bleeding in the morning, has not bled any more 
since the application of the caustic, but there has been a good 
deal of haemorrhage from another ; around all of the leech-bites, 
there are large patches of ecchymosis. The pulse is 78, regular, 
and of moderate strength ; the tongue is moister, and cleaner than 
in the morning, and is partially covered with a dark brown, in- 
stead of a yellow paste ; the urine is scanty, and resembles 
dark muddy ale in colour ; he has had some return of the epis- 
taxis, but no headach, abdominal uneasiness, or general pains ; 
he hears more readily than in the forenoon. He has had wine 
negus twice. 

1 7th September, (ninth dai/.) He slept well, but looks more 
collapsed than yesterday, and complains of confusion of ideas. 
His eyes have a keen, inquiring expression. The yellowness of 
the countenance seems to be still diminishing, and it is also less 
on the abdomen, but is more perceptible than formerly on the 
legs. There is no pain in any part of the abdomen, either on 
coughing, or from firm pressure of the hand. The leech-bites 
have not bled since last report, but there has been considerable 
epistaxis, and, according to his own statement, some haemopty- 
sis. The pulse is 98, and of good strength. He is inclined to 
sit up in bed, and does so for some minutes at a time, without any 
feeling of exhaustion. The bowels are regular; the urine is less 



54 



HIGHLY CONGESTIVE FORM. 



turbid than it was yesterday, but it has the same colour; there is 
some abdominal distension. — Continuatur mnum. — Haheat pilulam 
calomel, et opii, ter in diem. — Intermittatur haustus Jiord somni. 

ISth September^ {tenth day.) He passed a good night, and is 
very much improved in appearance. He has no confusion of ideas. 
The yellowness has almost disappeared from the face, fore-arms, 
and hands; but, although it has also much faded on the other 
parts of the body, it is still quite visible; in the sclerotics, it is de- 
cidedly less. The skin feels natural; the tongue is moist, and 
much cleaner, but on some parts, has a dark paste ; his bowels have 
been twice opened, since the visit yesterday; the pulse is 84, small, 
and regular; there has been no more bleeding from the leech- 
bites, nor epistaxis. — Continuentur omnia. 

19th Septeinher, (eleventh day.) His bowels have been once 
opened ; the tongue is moist, and cleaning; there is less thirst; 
the pulse is 88, of good strength; the skin is cold. 

20th September, {twelfth day.) He is going on well. There is no 
abdominal pain; but there is a very faint dark streak on the 
skin, extending from the umbilicus to the pubes. The mouth is 
not affected by the pills, which he has taken regulai'ly. He has a 
good deal of cough. — Omittantur pilidw. — Utatur linimento opiato. 

2\M September, {thirteenth day^ He slept well, and feels better. 
The yellowness has left the surface, and the sclerotics. The 
tongue is slightly furred, and moist; the countenance is natural; 
the deafness has increased; pulse 72, of good strength; he makes 
no complaint of pain in any part; the dark abdominal line is 
broader, but less defined than yesterday ; the cough is much less. 
— Quiescat. 

22d September, (fourteenth day.) Goes on improving; the dark 
line is seen faintly extending between the pubes and the ensi- 
form cartilage; the appetite is very good. — To have porridge in 
the mornings, as he disliJces the tea. 

2Sd September, (fifteenth day.) He is improving; and has been 
taking no medicines, excepting the wine, since the 20th. — Quiescat. 

24}th September, {sixteenth day.) He has not been so well since 
yesterday evening; he slept ill last night; the pulse varies from 
100 to 120, and is deficient in strength; the tongue is moist, but 
covered with a thin w^hite fur; to-day, and for some days past, 
there has been more deafness; the bowels have been opened 



HIGHLY CONGESTIVE FOKM. 



55 



thrice since last night; he has some dry cough. — Habeat troch. 
ipecac, et morpJi. xosv, 

25th September, (seventeenth day^ The pulse is as yesterday, 
but more irregular. He slept none during the night, but a little 
this morning. He has not had the lozenges, is much trou- 
bled with cough, and has a good deal of white frothy expectoration. 
At present, he complains of some cold, with slight rigors, which, 
he says, he has always more or less of at this time of day, (be- 
tween twelve and one o'clock.) He feels no pain in any part of 
the body, except a slight headach, which he attributes to the 
cough. The bowels are open. — To take one of the ipecacuan and 
morphia lozenges occasionally; and a draught, with thirty drops of 
the solution of muriate of morphia, at night. 

2lth September, {nineteenth day.) He goes on improving. — To 
have rice diet. 

\st October, {twenty-third day^ Since last report, he has been 
going on well, and now makes no complaint, except of debility, 
and general pains. He is allowed to rise to-morrow. — B. ex- 
tract, gentianw 3«. Ft. pil. xij. Sumatunam, quartet qudque hord. 

hth October, {twenty-seventh day.) He has been up during the 
greater part of each day, since the 2d, and has gone on steadily 
improving. He makes no complaint of weakness of the limbs, 
and the general pains have ceased. The appetite has returned. 
— To have full diet. 

9th October, {thirty-frst day.) He is dismissed, at his own re- 
quest, without any remaining symptoms of the fever, except some 
remaining weakness, and slight oedema of the ankles. 

Ist November. — Since the patient left the hospital, he has gain- 
ed but little strength, and when seen to-day at his house, was 
labouring under general dropsy, apparently independent of or- 
ganic disease, and solely caused by debility. He has been manag- 
ing himself very ill, and has had little good food. 

Case XV. — Summary. — In the first attach, {on 6th day), occurred 
yelloicness, dark coloured urine, bilious vomiting, and delirium. 
Critical sweating took place on the ninth day. He relapsed on 
the eighteenth day. The symptoms of the former attack were re- 
peated, with the exception of yellowness and delirium, and xoith 



56 



HIGHLY CONGESTIVE FORM. 



the addition of sweating. No epistaxis or other hemorrhage oc- 
curred in this case. — Recovery. 

Dominick White, an Irishman, aged 47, married, residing in 
Currie's Close, Grassmarket, by occupation a labourer, was 

Admitted^ ^Ith August^ {fourth day of the disease?) He 
states, that he has lived in Edinburgh for the last ten years. 
For the last twelve months, he has been only partially employed, 
and has had at times, insufficient aliment. He says, that he has 
descended from a healthy family, has always enjoyed good gene- 
ral health, and never had, before this attack, a disease simi- 
lar to it, or any other, termed fever. His appearance is robust. 
He has scanty grey hair, and light eyes. 

On the 24th August, at 12 noon, he was seized with rigors, 
pain of the head and back, and general soreness over the whole 
body. He has kept his bed, since the attack, till now. During 
this period, there has not been the slightest epistaxis, cough, 
vomiting, sweating, or diarrhoea ; and his symptoms have been 
just a continuance of those which first seized him, with the addi- 
tion of anorexia, and much thirst. He has been generally chilly, 
and has passed restless nights. On the day after his attack, he 
was seen by a medical gentleman, who prescribed some aperient 
powders, which operated freely, but without relieving any of the 
symptoms. His wife and family are at present convalescing from 
the prevailing epidemic fever. 

His pulse is 100, of moderate strength; the tongue is furred, 
and moist; there is much thirst; the bowels were opened 
to-day, before admission ; the temperature is somewhat in- 
creased ; there is no eruption ; he sleeps badly at night ; 
the headach is severe, but his intellect is perfectly clear; 
he complains of a saline taste in the mouth ; has no appetite ; 
is prostrated in muscular power; and is racked with general 
pains; he lies best on the left side; the chest expands 
freely, and without pain ; his respirations are twenty in the 
minute. — Ildbeat calomelanos gr. v, hord somni. — Etiam, pul. jala- 
pw compos. 3«', eras mane. — Admoveantur hirudines iv temporihus; 
et ahradatiir capillitium. 

2Uh August^ {fifth day.) — Ho feels easier to-day, and his 



HIGHLY CONGESTIVE FORM. 



57 



iiead is much relieved; his bowels have been opened by the 
medicine. — B. sulpJiatis magnesice acidi sulph, diluti gtt. 
s^rupi zingiheris aquw menthce 'pip, oij. Sohe^ et ft. Jiaustus. 
Bumat statim. — B. tartratis antimonii et potassce gr. % spiritus 
wtheris nitrosi ^ss, aqitw fontis ^mij. Misce, Bimiat unciam 
tertid qudque hord. 

Vespere. — During the afternoon, he sweated for about two 
hours, after which, he enjoyed temporary relief. 

SOth August, (seventh day^ — Since admission, he has slept little. 
The whole surface of the body acquired a decided yellow tinge, dur- 
ing yesterday. His pulse is 104, of tolerable strength; the tongue 
is moist, and coated at the centre, with a thin, dirty-yellowish 
paste; the bowels have been pretty open; he has twice had 
some bilious vomiting ; the urine is scanty, and of a dark-red 
colour ; there is no pain over the spleen, or any part of the abdo- 
men; and during a full inspiration, the diaphragm descends free- 
ly, without causing any uneasiness. — Habeat massw pihil, liydmrg, 
gr, -y, statim ; et eras mane, Jiaustus catJiartici ^iv. 

Vespere. Soon after noon, (when the above report was written,) 
he became incoherent, and could with difficulty be restrained in 
bed, so great was his propensity to wander about the ward. 

Slst August, (eighth day.) — He has not manifested any violence ; 
but during the night, disturbed his fellow-patients by incessantly 
talking, and, when not under the observation of the nurse, leav- 
ing his bed. His eyes are at present restless. The skin has 
a much yellower hue than yesterday ; and upon examination, it 
appears, that the bald scalp, neck, chest, and abdomen are the 
parts most vividly tinged. There is some very slight tenderness 
under the false ribs of the right side ; but no pain is excited by 
pressing on any other part of the abdomen, which feels soft, and 
natural over its whole extent. The tongue has the same appearance 
as yesterday; the pulse is 104, full, and very compressible; the 
bowels were moved by the blue pill; the cathartic draught has been 
taken at present, (half past 1 p.m.) He is free from pain, except- 
ing in the left knee-joint. — Habeat spirit, communis o'oiij, forma 
"' toddy.'''' — B.pilul. colocynth. comp., pilul. hydrarg. massarum dd 
gr. X. Misce, et divide in pilulas iv. Simat unam, tertid qudque 
hora. — Ht. haustum cum sol. mur. morphias 3«, hord somni. 

\st September, (ninth day.) Soon after the visit yesterday, he 

I 



58 



HIGHLY CONGESTIVE FORM. 



slept for about two hours, during which time he lay on his back, 
breathing stertorously, and bathed in warm perspiration; after 
this sleep, he had a waking interval of an hour, and again fell 
into a slumber. He slept well during the night, after getting 
the morphia draught. He has taken all the spirits, made into 
toddy. He has at present a disposition to slumber^ but is quite 
coherent, which he has been, with one very slight exception, 
since the first sleep of yesterday. There is a decided diminu- 
tion in the intensity of the yellow tinge, which, however, is 
fitill deep, and striking ; the tongue is cleaner, and moister than 
yesterday, but far back, there is still a good deal of the dirty 
yellow paste, formerly mentioned ; his pulse is 68, soft, and 
compressible. His only complaint is of feebleness. — Continuantur 
spiritm commimis^ et Iiaustus, liord somni. — B. masswpilul. colocynih. 
com/p.^ masses pUul, hydmrgyT% dd gr. iiss. Misce, ft. pihila, hom 
somni smienda. — Sumat liamt. catJiartici eras mane. 

\^tli September^ {eighteentJi day.) Belapsed. For some time 
past, he has been quite well, and gaining strength. The medicines 
and spirits were discontinued, on the day after the date of last 
report. This afternoon, he was seized with headach, general 
pains, vomiting, and sweating, which symptoms were ushered iij 
by heat of skin, without rigors. The bowels are confined. — 
Haleat enema purgans stafim. 

11th Septemher, (nineteentli day.) — He passed a restless night, 
from disturbance in the ward; his countenance is pale, and rather 
depressed; the bowels have been freely opened by the enema; he 
has slight general pains, but no headach. At present, he is 
perspiring profusely, and vomiting much. — Ht. mist, creasoii S*, 
et repetatur post Iioras dtias, si opus sit. 

Vespere. — No vomiting having occurred after the first dose of 
the creasote mixture, he did not take more of it. His linens 
have been shifted, since he ceased to perspire, and he now feels 
comfortable; the skin is moist, the countenance improved, and 
the expression more lively. No yellowness has appeared in the 
r elaps e . — Quiescat. 

12th September, \twentieth day.) He feels better, and slept 
well till disturbed by the vomiting, which returned with severity 
at three o'clock, a.m., but was checked by one dose of the creasote 
mixture. The tongue is moist, and somewhat mottled with a 



HIGHLY CONGESTIVE FORM. 



59 



white fur. He perspired a good deal during the night. He 
complains of nothing but debility. — Quiescat. Bepetatur mist, 
creasofi, si optts sit. 

iSth September, {twenty-first day.) He slept ill, but does not 
feel worse. The pulse is 84, and rather deficient in strength. He 
has had vomiting six or eight times, since the visit yesterday; the 
matter ejected last, which is now under observation, seems to be 
chiefly water, saliva, mucus of a rusty colour, and a small 
quantity of inky sediment. The nurse states, that what was pre- 
viously thrown up differed from this in being decidedly green, 
but was in other respects similar. Since yesterday, he has had 
three one-ounce doses of the creasote mixture. He has no pain 
in any part of the abdomen; and the bowels are open. — Ht. 
mist, creasoti li, sextd qudque hora, — To lime two lottles of soda 
'Water., and effervescing soda powders in moderation. 

14<th September, (twenty-second day.) He feels, and is better in 
every respect ; he has taken three ounces of the creasote mix- 
ture as directed, and had no return of the vomiting. — Quiescat. — 
Contin. mist, creasoti^ si opus sit. 

15th September, (twenty-fourth day.) He has had no return of 
the vomiting; the tongue is clean, and the appetite is returning. 
— Quiescat. 

20th September, (twenty-eighth day.) For some days past, he 
has been sitting up a little. Though the tongue is a little coated 
to-day with a white fur, he may be said to be going on well in 
every respect. — B. sulph. magnesice ^i, acidi sulph. aromatici 3^, 
aqu(^ fontis Ixij. Solve. Sumat ^ij ex aqua., omni mane. — Instead 
of the soda water, let him have a pint of ale. 

22«? September, (thirtieth day^ He feels quite well, and is 
daily gaining strength. — To have full diet. 

Dismissed on 2^th September, (thirty-seventh day^ Since last 
report, he has been in perfect health, and is now dismissed, strong 
and cured. 



60 



HIGHLY CONGESTIVE TORM. 



Case XVI. — Summary. — Yelloicness on tlie 8th day — Hemissmi 
— Relapse on the IQth day, accompanied with a return of the yel- 
lowness — -profuse sweating on 19th day — sudden occurrence of ex- 
treme debility on the 22c^ day. — Treatment; an emetic, calomel and 
opium, opiates and stimulants. — Recovery. 

Francis Eose, aged 87, married, of spare habit, with hazel 
eyes, an Italian strolHng organist, arrived in Edinburgh about ten 
days ago, upon one of his occasional visits, was 

Admitted, Octoher Tlst, {fifth day.) On the l7th October, he 
was seized with severe pain in the bowels, and rigors, followed by 
profuse sweating of the upper part of the body; he describes the 
perspiration, as having fallen from the face and forehead in large 
drops. He had no more sweating till to-day, when his skin be- 
came moist, but the perspiration was checked by exposure, on 
removing him to the Hospital. He has been very actively purged 
by a practitioner in the Grassraarket. 

He states, that he is healthy, and generally of regular habits. 
He attributes his seizure to having visited his wife,^ while she 
was a patient in this Hospital ; but with what justice, cannot, 
of course, be determined. There is no fever in the house where 
he has been lodging. 

The pulse is 85 ; the tongue is covered with a white fur ; the 
bowels are rather confined ; there is no eruption ; the intellect 
is clear ; he is free from headach ; he sleeps ill at night, which 
he attributes to his extreme tliirst. — Sumat statim, olei ricini, ^i. 

22d Octoher, (sixth day.) Yesterday, some hours after admis- 
sion, a slight temporary moisture came out on the skin. He slept 
none last night ; the pulse is 100, and soft ; the tongue is clean, 
and moist; since taking the castor oil, he has had four stools; he 
complains of some headach, and pain in the epigastrium, and ge- 
neral soreness. — Abradatitr capillitium. — Sumat tincturoB hyoscy- 
ami nigri gtt. xx, tertid qudque hord, ad tertiam mcem. 

2Sd Octoher, (seventh day.) He slept little last night. The 
pulse is 85, of moderate strength, and regular ; the tongue is 
moist, and coated with a white fur, except at the point, where 
there is a red triangle with its apex pointing inwards. — Quiescat. 

' For an account of her case, vide p. 16. 



HIGHLY CONGESTIVE FORM. 



61 



24itli Octoher, {eiglith da^/,) He slept none last night. The 
pulse is 84, soft, and feeble. There is a dusky-orange tinge 
on the surface of the body; it is most intense upon the face, 
neck, chest, and abdomen, and gradually fades towards the knees, 
where it abruptly becomes much less vivid, but still continues to 
manifest itself in considerable intensity, nearly to the ankles ; 
the arms present the same degree of yellowness as the inferior 
extremities below the knee; the transition from the deep yellow 
of the chest and neck, to the fainter hue of the arms, is more 
gradual than that observed at the knee, but may still be said to 
be abrupt. There is much increase of dulness in the hepatic re- 
gion; and a good deal of pain is excited when pressure, either firm 
or gentle, is made in that situation; there is pain across the epi_ 
gastrium, and also, though in a less degree, over the spleen, and 
above the pubis ; he has considerable nausea, but has vomited only 
the water which he had taken, and a very small quantity of ropy 
mucus of a lightish brown colour; he has made water twice to-day 
w^ithout pain ; he has had one stool, but neither the alvine nor 
the urinary evacuations have been kept for inspection ; he com- 
plains of dryness of the mouth, and a good deal of thirst ; the 
tongue, which is chapped and coated with a dark yellow fur, has 
the same appearance at the point as yesterday. — B. sulpJiatis zinci 
gr. ccv, aquw fontance Ivi. Misce. Statim sumat.-r-Haleat vini 
ruhri ^% forma '^negus,'''' peracta vomitione. — B. pilulas calomela- 
ms et opii iv. Smzaf unam^ secundd qudque Jiord. 

25th October (ninth day?) The emetic was administered yester- 
day, between 3 and 4 p.m., and speedily emptied the stomach, with- 
out causing much straining, or subsequent depression. The mat- 
ter ejected consisted chiefly of water. Immediately after the ope- 
ration of the emetic, he got some port wine negus, which he vomit- 
ed ; but he retained in his stomach a small quantity given to him 
shortly afterwards. He felt much better soon after the vomiting 
ceased, and continues so at present. He has had four calomel 
and opium pills since yesterday. The bowels have not been 
opened during the last twenty-four hours; but there is no pain 
of any part of the abdomen, except immediately above the 
pubes, where there is some uneasiness, increased by pressure, and 
also a constant feeling of tightness; there is some tympanitic dis- 
tension of the abdomen. The urine is scanty, and of a brown 



62 



HIGHLY CONGESTIVE FORM. 



colour, but not so dark as porter, and is passed with some pain 
and difficulty. He slept at intervals during the night, and felt 
comparatively comfortable, being perfectly free from pain, from 
which, also, he does not suffer in the least, at present. The 
yellowness is perceptibly less intense; the pulse is 64, soft, and 
regular; the tongue is much as it was yesterday; the skin is soft, 
and of natural temperature; the expression of the countenance 
is improved. He has had gij-iij of wine in addition to what was 
ordered yesterday forenoon. — Injic. enema foetidum^ statim. — 
Continuatur viiimi ruhrwn ad ^v. — Habeat calomelanos gr. forma 
pilulanmi ij^ et haustum cmi sol. mur, morpMw Zss, Jiord somni. 

2Qth Octoher^ {tenth day.) The injection was administered, and 
operated four hours afterwards; he also had the calomel, as 
ordered. Last night, the bowels were opened once, and again, 
this morning; the stools, on both occasions, were fluid, of a dark- 
brown aspect, and bearing a striking resemblance to thick hare- 
soup, both in colour and consistence. The yellowness, tongue, skin, 
and urine, remain much as yesterday. The pulse is 74, soft, and 
natural. There is still a degree of tympanitis, but it has much 
diminished. He says, that he has a sweet taste in his mouth. 
His expression continues to improve. — Injic. enema foetidum; 
et Jiaheat pil. calomel, et opii ij, vespere. 

27th October, (eleventh day.) He has slept at intervals, since last 
report. The yellowness is passing into a brassy bronzing; the 
tongue is clean, and moist; the pulse is 68, soft, but feeble; 
there still remains a very slight degree of tympanitis; there has 
been a discharge of dark-brown fluid matter from the bowels; 
the urine is somewhat lighter in colour. — Augeatur mn. rubrum 
ad m. — To have beef-tea. 

2^th October, {twelfth day.) He has gone on impro^^ng since 
yesterday. The countenance is rapidly becoming bronzed. — 
Habeat pil. calomel, et opii i, vespere. — Habeat olei ricini ^i, hord 
somni. 

SOth October, {fourteenth day.)- — He has improved considerably 
since last report. The bowels were moved yesterday, by the 
castor oil taken the preceding night; and this morning, he had a 
stool naturally. The countenance has a dirty coppery appearance ; 
the expression is tranquil; the skin is soft, and natural. The yel- 
lowness of the surface of the body is extremely faint, but still 



HIGHLY CONGESTIVE FORM. 



63 



quite apparent; while it has entirely left the conjunctivse. The 
pulse is 58, soft, and rather compressible; the tongue has a grey- 
ish colour, owing to being slightly coated with fur, and feels 
clammy, rather than moist. He has had neither sweating nor 
diarrhoea, since admission. — R. sulph. quininw gr. cccciv, extracti 
gentiancB lut, q. s. ut ft. massa^ in pil. xxw dimdenda, Sumat i, 
ter in diem. 

1st JVovanher^ {sixteenth day.) During yesterday afternoon 
and last night, he felt cold, and shivered; he had also much head- 
ach, and vertigo, which latter he feels at present. He has had 
no sweating; the yellowness has become more marked; the pulse 
is 100, firm, and regular; the tongue is coated with a grey adhe- 
sive paste; the bowels are confined; there is much thirst; great 
heat of skin; and general pains. — Intermittantur pilulw sulph. 
quininw. — Haheat pil. hydrargyria sextd qudque hord. — Injic. 
enema domesticu/m, eras mane. 

2d N'ovemher, {seventeenth day.) He slept a little during the 
night. The countenance is rather more dejected than yesterday. 
The yellowness is considerably diminished; but is still deeper 
than it was before the relapse. This morning, he had two dark- 
coloured stools, feculent, but not formed; the urine has somewhat 
of the porter colour, but is not so dark as in the first attack; 
the pulse is 100, and of tolerable strength; the tongue is moist, 
and almost clean; he has severe general pains, but no epigastric 
tenderness; he has had no vomiting. — To have an allowance of 
sago.-' — Haheat enema cum sol. mur. morphiw 555, vespere. 

Zd November^ {eighteenth day.) Last night, between seven and 
eight o'clock, he vomited a quantity of brown matter, tinged with 
green; but the sickness was checked by an ounce dose of the 
creasote mixture; it recurred, however, between nine and ten 
o'clock, when a similar dose was administered; and since then, he 
has not been troubled with it; the quantity of fluid ejected on 
both occasions has been now found to measure eight ounces. He 
complains of great pain in the epigastrium. He has an extremely 
weak, and dejected appearance; the face is bronzed ; his pulse is 
100, and feeble; he has taken no food for the last thirty-six hours, 
his only sustenance having been wine negus. — Augeatur vinum 
ad ^xij. — Applicentur cafaplasmata assidu^ epigastrio. 

^th November.^ {nineteenth day). As he vomited the wine seve- 



HIGHLY CONGESTIVE FORM. 



ral times during yesterday afternoon, he was ordered four ounces 
of whisky, mixed with forty drops of the solution of the muriate 
of morphia. He vomited the first half ounce of it, which had 
been administered in the form of toddy, but retained the remain^ 
der, which he got undiluted; and in addition, he has had eight 
ounces of wine. According to his own statement, and that of 
the nurse, he was much better at seven o'clock this morning than 
he was yesterday, or than he is at present. The countenance is 
improved. Perspiration began at four o'clock a.m., gradually be- 
came more copious, and continued very profusely till ten o'clock, 
when his shirt and sheets were shifted. This is the second sweat 
which he has had since admission, and the fourth since the inva- 
sion of the disease: it has relieved the general pains, except some 
pain in the back, which he felt previously. The epigastric tender- 
ness is very slight; the pulse is 62, soft, and regular, but very 
feeble; the tongue is much as yesterday; he has had two stools 
since yesterday, which are much less dark in colour, and quite 
fluid. — Let the wine he reduced to ^vi, and let him hme om of 
whisky^ containing Z^ss of the solution of the muriate of morphia. 

^th Novemher^ {twenty-third day.) He continued very much in 
the same state as that described in the report of the 4th, till last 
night, when he suddenly became weaker, and dissolution seemed 
to be impending. His countenance is extremely dejected. He 
complains of severe pains in the joints. His pulse is 54, and of 
tolerable strength; a few hours ago, it was 45 only; but since 
then, he has had some wine. The bowels were opened this morn- 
ing, and the matter evacuated is quite natural; the tongue is 
clean, and moist; the skin is soft; the intellect is clear, and he 
has had no incoherence. He vomited a good deal of the wine. — 
Omiitatur mnum. — Continuatur spirit, communis ad ovi^ cum sol. 
mur. morpMcG. 

9th November, (ttventy-foicrth day.) There is a marked im- 
provement in his appearance to-day. His pulse is 84, and of 
somewhat better strength. 

iOth November, {twenty-fifth day.) The improvement in the 
general appearance continues. The pulse is 80, and of the same 
strength as yesterday; the tongue is clean, and the bowels are 
open. He has a good deal of cough, attended with expectora- 
tion. Some degree of pain remains in his shoulders and knees, 



HIGHLY CONGESTIVE FORM. 



65 



but it is less than formerly. About five ounces of the mixture 
of whisky and morphia remain, the rest he has taken, without 
vomiting any of it. — Bj. acetatis plumhi gr. xxiv, puh. scillce gr. 
wij, mucilaginis q. s. ut ft, mctssa, in pilulas coij dimdenda, Sumat 
unam^ secundd qudque hord. — AppUcetur sinapisma pectori statim, 
€t repetatur post horas sex~Haheat pedilumum hord somni. — The 
mixture of whisky and morphia to he discontinued, 

\hth November^ {thirtieth day.) The prescriptions of the 10th 
had the desired effect. He has been gaining strength daily; and 
yesterday, and to-day has been able to sit by the fireside for a short 
time. Since the whisky was discontinued, he has had neither 
stimulant nor cordial. — Let him ham a pint of porter daily. 

21st November., {thirty-sixth day.) He is dismissed cured. 

Case XVH. — Summary. — Yellowness on the Qth day., and dark 
purple spots on the ^th — Remission — Relapse on the 14ith day, with 
recurrence of the yellowness. — Treatment; calomel and opium., 
aperients., S^c. 

Wilham Dodds, a native of, and constantly resident in Edin- 
burgh, living at present in the Pleasance, single, aged 20, a car- 
penter, of spare habit, with dark hair and eyes, was 

Admitted^ on dth October, {sixth day.) He was seized on the 
4th with rigors, headach, and pains in the back, and limbs. 
Since then, the symptoms have increased, with the addition of 
sleeplessness, and to-day, yellowness of the skin has appeared. 

The pulse is 96, of good strength; the tongue is white, and 
moist; the bowels are open ; he has much thirst; the headach is 
severe; the intellect is clear; there is a sweetish, saline taste in 
the mouth ; he feels much weakness. There is moderate yellow- 
ness, excepting of the extremities ; the tinge of the face, and 
neck, is very marked. — Ahradatur capillitium; et applicetur assidu^ 
aqua frigida toto capiti. 

10th October, {seventh day.) He is much as yesterday. A pro- 
fusion of dark purple spots has appeared all over the body. — 
Habeat pilulam calomelanos et opii, vesper e, et repetatur eras mane, 

11th October, {eighth day.) There has been little if any change 
since yesterday. From negligence, he has not had the pills which 
were ordered. The bowels are confined; the urine is of a very 

K 



66 



HIGHLY CONGESTIVE FORM. 



dark-red hue. — A hlue pill has been just now administered; and 
another is ordered to he given in the evening. — Let a purgative 
enema he injected immediately. 

12th Octoher, {ninth dai/.) He got the medicines which were 
prescribed. He slept well, and feels much better. The pulse 
and skin are natural; the tongue is cleaning; the muscular and 
articular pains are pretty severe. The yellowness has almost 
disappeared from the face, and general surface, but is still very 
marked on the sclerotics; the appetite is returning. — To have rice 
diet. — Haheat haustum cum solutionis muriatis morphiw gtt. xl, hord 
somni. 

ISth Octoher, (tenth day?) The tongue is moist, and nearly 
clean; the yellowness is now extremely faint, but is still distinct; 
he feels much better, and complains only of general pains. — 

<^uiescat. 

Vjth Octoher, {fourteenth day.) For the last two days, he has had 
rice diet. He went on well, till this forenoon, when he was seized 
with the relapse, which is marked by symptoms similar to those 
of the invasion. There is at present no yellowness. — Applicetur 
<tqua frigida toto capiti.—To have low diet. 

Idth Octoher, {sixteenth day.) The yellowness has returned in 
some degree. He has frontal headach, intense general pains, and 
sleeplessness. The face is bronzed over the malar bones; else- 
where, it is very yellow. — Two hlue pills have heen given just noio. 

20th Octoher, {seventeenth day.) He has had no stool since the 
blue pills were given yesterday. He slept none last night, al- 
though he had an anodyne draught. The yellowness has become 
much more intense. — Haheat olei ricini ^iss, statim; et injiciatur 
enema domesticum h. s., si opus sit. — R. solutionis muriatis morphice 
gtt. XXV, tincturce hyoscyami nigri Zss. Misce, et ft. haustus, h. s. s. 

21st Octoher, {eighteenth day.) As the oil operated, the enema 
was not administered. He slept ill last night. There is some 
abdominal uneasiness; the tongue is loaded with a yellow fur; 
on the face, the bronzing is beginning to predominate over the 
yellowness, which is facing on the whole surface. — Haheat pilulam 
calomelanos et opii, tertid qudque hord. 

22d Octoher, {nineteenth day.) The bronzing is much more 
distinct than yesterday ; there is only a slight trace of yellowness 
around the mouth. On awaking during the night, and feeling 



HIGHLY CONGESTIVE FORM. 



67 



thirsty, he drank a large quantity of cold water; after which, 
violent rigors came on, but the coldness soon left him, and was 
replaced by burning heat, although the trembling continued. 
While in this state, bottles of hot water were applied to his feet, 
and round his body; some wine negus was given him; and in 
about half-an-hour from the invasion of the rigors, a profuse per- 
spiration broke out, which lasted two hours. He has taken three 
of the calomel and opium pills ordered yesterday. The tongue 
is less loaded; the pulse is 78, full, but rather compressible; there 
is no abdominal uneasiness; the muscular and articular pains 
have almost left him; he looks, and feels much better; the bowels 
have not been opened since the 20th, when he had the castor oil. 
— Haheat enema purgans statim. 

26th October, (twenty-third day.) He complains of pains in the 
shoulders, arms, and legs; but is decidedly improving. — To have 
full diet to-morrow. 

'^Itli Octoher, {twenty-fourth day.) He rose this morning, but, 
owing to the severity of the general pains on motion, he was not 
able to dress, and had to go to bed again almost immediately. 
His appetite is good. 

2d November, (thirtieth day.) Since last report, he has been 
troubled more or less with diarrhoea, which has, within the 
last two days, been very severe, and has resisted the remedies 
prescribed, — viz. the decoction of logwood, in one-ounce doses 
every three hours, the electuary of catechu combined with the 
chalk mixture, and a starch enema containing forty drops of 
laudanum. — At present the complaint is unabated. — R. opii gr. 
iij\ micw panis, et conserves rosarum q. s. ut fiat massa in pilulas 
ccij dividenda. Sumat unampost sedem singidam liquidam. — Habeat 
suppositorium c. opii gr. iij\ hord somni. 

Sd November, 1 p.m. (thirty-first day.) He had no stools till mid- 
night, between which time and the present he has had eight, 
which is a diminution in their frequency, as compared with yes- 
terday. From negligence, five only of the pills have been given 
him. — Let him take one every hour till they are done. 

4tth November, (thirty -second day.) The pulse is 72, and rather 
feeble; his bowels have been opened five times, since last report; the 
stools are feculent, partially formed, and streaked with blood, and 
mucus. He complains of general abdominal uneasiness, when pres- 



68 



HIGHLY CONGESTIVE FORM. 



sure is made; particularly, when a part, about the size of a crown- 
piece, in the mesial line, nearly midway between the umbilicus and 
pubes, is touched. There is no fulness in either hypochondriac 
region. — Injiciatur enema amyli c. tincturce opii Ziss^ statim. — Hcu- 
heat pilulam pliimhi opiatam^ qudrta qudque hord. 

lltli Novemher^ {thirty-ninth day.) He went yesterday from 
the Fever Hospital to Ward No. 4, Royal Infirmary, that he 
might continue a few days longer under observation. The diar- 
rhoea has almost ceased ; and he is very anxious to leave the 
hospital. There is a dark stripe extending between the umbili- 
cus and pubis. It has appeared since yesterday. — Let Mm ham 
full diet. 

IS fh Novemher^ {forty-first day?) To-day he is dismissed to- 
lerably strong, and free from complaint. The dark stripe re- 
mains. 

Case XVIII. — Summary. — Purpura^ yellowness^ hare soup vomit, 
and haemorrhage from the lungs in the first attack — Relapse on the 
IZth day^ the remission between it and the first attach being ill 
marked — Becovery. Treatment; calomel and ojnum, wine. 

Alison Wilkie, aged 46, the mother of ten children, of ordinary 
development, with dark hair, and hazel eyes ; a native of Edin- 
burgh, where she has been all her life, at present residing in the 
Horse Wynd, was 

Admitted on SOth September, {sixth day.) She was seized 
on the 25th September, with languor, rigors, severe headach, 
and acute general pains, but has had no sweating since the 
invasion of the fever. The epidemic fever has been in the family. 
At present, the pulse is 118, and small; the tongue is dry, and 
dark coloured; she has great thirst; there is distinct, but not 
very vivid yellowness of the conjunctivae, face, neck, chest, and 
abdomen; the headach is not severe; the bowels are open. — 
Abradatur capillitium, et postea appUcetur aqua frigida toto 
capiti. 

1st October, {seventh day.) The report of yesterday was made 
with an imperfect light in the ward, and on that account, the 
state of the skin could not be examined with sufficient care. 
To-day, the yellowness is very decided on the conjunctivae, 



HIGHLY CONGESTIVE FORM. 



69 



face, chest, arms, and abdomen; on the legs, it is somewhat less 
intense. Upon the abdomen, and arms, the yellowness has a 
purplish tinge, and there are small purple spots scattered about 
irregularly in these situations, to which the neighbours attracted 
the notice of the patient three days ago. She does not seem to be 
worse than yesterday, but there is no amendment ; the bowels 
have not been opened since Sidmission.—Raheat enema purgans^ 
statim, — Sumat pilulam hydrargyria liord somn% et repetatur eras 
mane.-^Haheat vini ruhri ^'oj, forma negus.'''' 

2d October, (eighth day.) She passed a restless night. Yester- 
day afternoon, she vomited a good deal of black-coloured matter, 
which the nurse describes as resembling hare soup, but unfortu- 
nately it has not been preserved; there has been slight haemor- 
rhage from the gums, which she never had before; the pulse is 
100, and somewhat deficient in strength; the bowels were opened 
by the enema; she had the blue pills as ordered. — Sumat pilulam 
calomelanos et opii, sextd qudque hord, ad quartam mcem. — Conti- 
nuatur mnum. 

Sd October, (ninth day.) There has been no more vomiting, 
nor haemorrhage from the gums; she passed a comfortable night, 
and slept some; the yellowness has faded considerably, and the 
countenance is improved; the tongue is parched, and on its 
centre there is a brown stripe; the pulse is 116, soft, ^and defi- 
cient in strength; the skin is cool, and natural; she has had se- 
veral dark stools; the urine is scanty, and porter-coloured; she has 
some cough; there is no sweating. The pills and wine were ad- 
ministered as prescribed, — Continuatur vinum. — Haheat trochiscas 
morphiw et ipecacuanhw xoc. Sumat j ml ij, urgente tussi. 

4iih October, (tenth day.) The purple spots cannot be seen; 
the yellowness is disappearing rapidly; and in every respect, she 
is improving. — Continuatur vinum. 

5th October, (eleventh day.) The improvement certainly conti- 
nues, though the patient does not think so ; she spits up a quan- 
tity of very tenacious mucus, occasionally containing black car- 
bonaceous-looking masses, of the size of a large pea, which give a 
sooty streaking to the sputa; the urine is much more abundant, 
and has now a straw-colour; some scalding pain attends mic- 
turition; the tongue is clean, and moist; the pulse is 90, small 
and thready. — Let a bottle of porter be substituted for the wine. 



70 



HIGHLY CONGESTIVE FORM, 



Qth October^ {twelfth clay.) The expectoration continues as 
yesterday, and there is some pain in the chest, with a continual 
tendency to sleep ; the pulse is rather firmer. — Apply a blister^ 
three inches hy three., to the chest., for three hours; and then a 
poultice. 

1th October^ {thirteenth day.) The blister rose well; the expec- 
toration has greatly diminished in quantity, and is of a lighter 
colour; the pulse is 96, and deficient in strength.— l^o have cold 
heef tea for ordinary drinJc. 

Vespere. — She had a severe fit of rigors at 8 p.m. 

12ifA October., {eighteenth day.) Since last report, (excepting on 
the 8th), there has been a very slow, but steady convalescence. 
The bowels have been regulated by castor-oil. The debility is 
still extreme ; general soreness, with articular and muscular pains 
cause her great agony at times, and almost prevent motion. 

2d November^ {thirty-ninth day.) The wine was discontinued 
some days ago. She has made a complete recovery, and is now 
dismissed quite strong, and free from all pain. 

Case XIX. — Summary. — Bronzing oftlie countenance before seizure 
— Short remission and delirium on the Sd day — Yellotoness of 
conjunctiva on Sd day, and of general surface on oth — Spots on 
^th day — Severe headachy vomiting., and sweating — Slight rigors 
on the \ Uh day; but no relapse. — Recovery. Treatment; calomel 

' and opium, morphia, stimulants, quinine. 

Dr Heude, born in India of English parents, resident in Edin- 
burgh during the last three years, single, aged 23, of nervous 
temperament, spare, muscular frame, with dark hair and eyes. 

Took ill on 21st September. During the last six weeks, he has 
been resident clerk in the New Fever Hospital. His previous 
health has been good. His habits have been studious. 

He was seized with severe headach, nausea, pain in the back, 
a feeling of chilliness, languor, anorexia, and much thirst about 
the close of the noon visit. He slept well last night, and pre- 
viously, he showed no symptoms of the fever, except bronzing. 

His pulse is 120, full, and soft; the tongue is moist, clean in 
front, but coated with a brown fur behind; the bowels are con- 
fined; the temperature is increased; the skin is dry; tliere is no 



HIGHLY CONGESTIVE FORM. 



71 



eruption; there is very severe headach; the intellect is clear; 
there is a bad taste in the mouth; he is greatly depressed in 
strength; the expression is anxious, and the face is much bronzed; 
there is some cough. — Ahradatur capillitium; et appUcentur Jiirw- 
dines mij temporihus. ' — AppUcetur aqua frigida capiti. — Habeat 
pilulam colocyntli. compos. — Injiciatur enema purgans^ si opus sit. 

22d Septemher, {second day.) The symptoms continue, with 
vomiting, and increased headach. This morning, about six 
o'clock, he had profuse sweating. The head was shaved, and 
the leeches bled freely for a long time. The bowels have been 
opened by the medicine ordered yesterday. 

23 September^ {third day.) Eight leeches have been twice 
applied to the head, since last report. The symptoms are much 
the same as yesterday. The nurse states, that there was a re- 
mission, early in the morning. He slept none during the night. 
The conjunctivae are congested, and have a slightly yellow tinge* 
He has had a good deal of vomiting; and the headach is as 
severe as formerly. He has been very incoherent to-day. There 
was a fit of perspiration at 7 a.m. 

24ttJi September^ {fourth day.) He slept some, after taking, 
about midnight, a draught containing twenty-five drops of the 
solution of the muriate of morphia. He is more restless, and in- 
coherent to-day. He sweated at eight o'clock this morning. 

2Qth September^ {fift^ day.) He passed a restless night, but 
had some sleep towards morning, after getting an injection con- 
taining half a drachm of the solution of morphia. He sweated 
profusely at 4 a.m.; but, as on the former occasions, has been 
in no way relieved by it. The whole surface of the body has a 
dusky yellow colour, but there is less of this on the arms and 
legs than elsewhere; there is very slight increase of dulness over 
the liver, and none over the spleen, and in neither region is there 
any tenderness. It is difficult to describe the colour of the coun- 
tenance. Over the malar bones, a deep purple hue preponder- 
ates over the yellowness, which is general elsewhere. He has 
no abdominal uneasiness, but severe general pains, and headach. 
^Haleat pilulas calomelanos et opii duas. 

' The leeches were applied at Dr Heude's urgent request, and with Dr Alison's 
sanction* 



72 



HIGHLY CONGESTIVE FORM. 



2QtJi Sejptember^ {sixth day.) The symptoms are aggravated 
to-day; the yellowness is as yesterday. Early this morning, the 
nurse observed some spots on the chest. About 11 a.m., (when 
now examined), they are irregular, of nearly the size of a 
split-pea, and of a pale lake colour. They do not disappear on 
pressure. He had an enema last night, containing a full dose of 
the solution of the muriate of morphia. 

27^A Septemher., {seventh day.) The pulse is feebler to-day, and 
variable. The incoherence, headach, and general pains continue. 
The spots, which became deepened in colour last night, are now 
purple. The urine is frothy, and as dark as porter. He has 
had three calomel and opium pills since yesterday, and one assa- 
foetida and aloes pill, which opened the bowels. He has had a 
small quantity of wine. 

2^th September^ {eighth day?) Noon. He was very violent 
during the night, and required to be kept in bed by force. When 
seen at 3 a.m., his pulse was 130; at 5 o'clock, it had fallen to 
100; and it is at present 102, and very feeble. Though some- 
what incoherent and desponding, he lies quiet. He has passed 
two tarry stools; the urine is still porter-coloured; the yellow- 
ness is slighter; the petechial eruption is very marked. During 
the last hour, he has had about three ounces of wine, which has 
improved his pulse somewhat. 

2 P.M. The pulse is 90, and firmer. He has had about four 
ounces of wine since noon. 

6 P.M. Pulse 80. His countenance is improved. 

11 P.M. Pulse 82. He is quiet, but has no tendency to sleep. 
— To have a calomel and opium pill. — Let the feet he hathed in hot 
water., immediately. 

I^th September^ {ninth day.) He passed a tolerable night, and 
is to-day a good deal better. He has had two stools of a tarry 
consistence and colour. The urine is rather paler. 

5th Octoher., {fifteenth day.) Vespere. Since last report, he 
has been steadily, but slowly improving, under the liberal use of 
stimulants. Yesterday, he was ordered an eight-ounce quinine 
mixture, containing twenty grains of the sulphate, of which he 
has taken three-fourths. This afternoon, he had a feeling of 
chilliness, after which a profuse sweat broke out, (the first 
since the morning of the 25th September), and he is still per- 



HIGHLY CONGESTIVE FORM. 



78 



spiring. Since yesterday, he has had no general pain or head- 
ach. His appetite is good; his strength is increasing; the 
countenance is now almost natural, and so are the alvine and 
urinary secretions. 

26th November. Since last report, he has had no symptoms of 
the fever, and he has now resumed his hospital duties. The conva- 
lescence was steady, under the liberal use of wine and ale. The 
quinine mixture was continued for eight days. 

Case XX. — Summary. — -Bronzing before seizure — Bosy lenticular 
spots on tJw Qth day — Yellowness on the 8th day — Pustular 
eruption on the \^th day — Salivation during the intermission^ 
from mercury talcen during the first attacJc — Bela'pse on the Idth 
day. — Treatment; opium^ calomel and opium^ quinine^ hydrio- 
date of potash^ wine. — Becovery. 

Mary Wallace, Scotch, a widow, aged 36, day-nurse in the 
female wards of the New Fever Hospital, of spare habit, with 
brown hair, and light eyes. 

Became a patient on 1st October. — During the last week, she 
has been in almost constant attendance in the apartment of 
Dr Heude, who has the prevailing fever. Since an attack of rigors 
four days ago, she has been complaining of languor and debility, 
pain in the back, headach, thirst, bad taste in the mouth, and 
occasional nausea. Her tongue has been foul; her bowels have 
been pretty regular; her face, during a longer period, has been 
bronzed, (even before she felt unwell,) and latterly, became almost 
purple. 

The pulse is above 100, of tolerable strength; the tongue is 
moist, clean in front, and covered with a thin brown fur behind; 
there is intense thirst; the bowels are rather confined; the skin 
is hot, and dry ; there is no eruption ; the headach is very severe ; 
her intellect is clear; she has a bad taste in the mouth; her mus- 
cular powder is greatly depressed; the expression of the face de- 
notes much suffering; there is bronzing of the countenance, and 
on the upper part of the cheeks, a purple hue is perceived. — B. 
pulveris scammonii gr. viij\ calomelanos gr. iij. Misce. Sumat 
statim. — Applicetur aqua frigida capiti. 

2d October^ {fifth day.) The pulse is 104, rather deficient in 

L 



74 



HIGHLY CONGESTIVE FORM. 



strength; the tongue is moist, and only slightly coated with a 
white fur; the bowels have been freely opened; there is intense 
headach; and much thirst. The countenance is more depressed; 
the face is less purple, and more bronzed. — Ahradatur capilli- 
tium, et applicetur lotio muriatis ammonim capiti.—Haheat haustum 
cum tincturw Tiyoscyami 3^, hora somni. 

3d October, (sixth day,) half-past 1 p.m. — She has suffered much 
from restlessness, sleeplessness, and headach, since yesterday. 
The pulse is 108, and of the same strength as yesterday, — cer- 
tainly not weaker; the tongue is slightly white, and moist; the 
bowels are confined; she has a good deal of pain in the back. 
There is much nausea, with vomiting of a green fluid with an inky 
sediment. The countenance denotes suffering, but not depression. 
On the chest, are about ten rosy spots, which disappear on pres- 
sure, but return vividly when it is removed. She has taken half 
an ounce of the creasote mixture. — Habeat pilulam hydrargyri 
statim, et repetatur cms mane. — Swnat misturw creasoti unciam, 
qimrta quaque hora, si opus sit. — AppUcetur sinapisma epigastrio; et 
linimentum saponis cum opio ahdomini, et regioni lumhis. 

Vespere. Since the former report was made, (between 1 and 2 
P.M.), there has been a good deal of delirium, with restlessness, 
and the desire to rise from bed, which she has done frequently. 
She has intense headach, general pains, and some abdominal 
uneasiness. The eruption is spreading over the arms, but not 
on the abdomen, or legs. — Haheat haustum cum solutionis mu- 
riatis morphias -^iss, hora somni. — Injiciatur enema picrgans, eras 
mane. 

4ith October, (seventh day.) The creasote mixture did not re- 
lieve the vomiting; but she only took two doses. She slept some 
after the draught, with occasional fits of perspiration and chilli- 
ness during the night, and is now lying quiet and collected, de- 
cidedly better. There is slight drowsiness, the effect probably 
of the large dose of morphia; the pulse is 78, rather deficient in 
strength; the skin is cool, and natural; the bowels have been 
very freely opened by the pills and enema; the tongue is parched, 
and clean, excepting in the centre, where it is a little brown; 
there is much thirst. — Quiescat. 

5th October, (eighth day.) Towards midnight she became rest- 
less, and afterwards had a good deal of delirium, with desire to 



HIGHLY CONGESTIVE FORM. 



75 



rise from bed, especially on awaking from short, disturbed slum- 
bers. There is a slight yellow tinge on the skin of the face and 
neck; but on the former, the bronzing predominates. The vo- 
miting is much less urgent; the bowels are not freely open, but 
there is a constant desire to evacuate them; the tongue is fur- 
red, and dry; the general pains, which are still severe, have 
been somewhat relieved by friction with the soap and opium 
liniment; the urine is scanty, and of a dark colour, approxi- 
mating to that of porter. She is extremely restless; and her 
countenance indicates suffering. — Hdbeat pilulam calomelanos et 
opii, tertid qudque Jiord. — Injiciatur enema piirgans^ eras mane. 

6th October^ {ninth day,) She has taken six calomel and opium 
pills, and had a good deal of disturbed sleep during the night. 
Her countenance is much improved; the pulse is 86, of good 
strength; the tongue is clean, but parched; the eruption is 
fading, but still visible; the yellowness is fainter than yesterday. 
— Haheat olei ricini ziss^ statim. — Haheat acidi sidphurici diluti gtt. 
wv ex aquGB fontis ter in diem^ pro potu. 

1th October^ {tenth day?) She slept none last night. The pulse 
is 76, and of moderate strength; the tongue is clean, and moist; 
she has passed very foetid, dark, melsena-looking stools. The yel- 
lowness has entirely left her ; the eruption is still visible, and has 
not faded any since yesterday; the face is much bronzed. — R, 
calomelanos gr. iij\ pidv. rhoei gr. mij\ pulv. zingiheris gr. ij. Misce. 
Fiatpuhis^ mspere sumendus.- — Haheat haustwn^ cum solutionis mu- 
riatis morphice gtt. xxccv, hord somni. 

Sth October, (eleventh day.) She had a disturbed night, having 
been much troubled with diarrhoea. — Injiciatur statim enema 
amyli cum solutionis muriatis morphice gtt. cel. — H. opii puri gr. ij\ 
conservw rosarum q. s. ut fiant pilules tres; haheat imam quartd 
qudque hord. — Haheat mni rubri ^iv. 

9th October, (twelfth day.) The bowels have been twice open- 
ed, without much pain. She passed a pretty good night. The 
pulse is 96, of moderate strength; the tongue is clean. — Haheat 
haustum cum solutionis muriatis morphice gtt. xl, hord somni. 

11th October, (fourteenth day.) She has been improving since 
last report. Yesterday, a pustular eruption appeared on the chin, 
and angles of the mouth. To haw steak diet. 

12th October^ (fifteenth day.) She continues to improve. — R. 



76 



HIGHLY CONGESTIYE FOR:sr. 



sulphatis quinince Qi, acidi sulplmrici diluti 9^*, infusi gentiance 
^iv. Misce. Sumat ^ss, sextd qudque liord. 

14<th October, {seventeenth day.) She cannot take the quinine. 
She has soreness of the gums, with looseness of the teeth. — Omit- 
tatur mistura quininw, — Utatur melle horacis. — R. hydriodatis 
potassce aquce fontis ^iv. Solve. Sumat Zi, quater in diem. 

16tli October {nineteenth day.) She continued to improve, till 
this morning, when she was suddenly attacked by headach, ge- 
neral pains, and vomiting. Yesterday, she was going about the 
wards, using too much freedom with herself. — To have low diet. 
— R.pulveris opii gr. ij\ conservce rosarim q. s., ut fiant pilulm iv. 
Sumat unam quartd qudque hord. 

ISth October, {twenty-first day^ She is suffering much from 
vomiting, headach, and general pains ; the pulse is very frequent. 
— Repetantur pilulw opii ut antea. Injiciatur enema amyli cum so- 
lutionis muriatis morphim Zss. 

19th October, {twenty-second day.) She is in all respects much 
better. 

26th October, {twenty-ninth day.) Slight pains in the arms and 
shoulders continue. She feels quite well, but weak ; and is allow- 
ed to go out to walk for an hour. 

Mh November, {thirty-eighth day.) Though still weak, she is 
quite well; and has this day resumed her duties in the wards. 

24#7i November, {fifty-eighth day^ She is now in excellent 
health, and has been gaining strength progressively since last 
report. 

Case XXI. — -Summary. — Slight yellowness on the lOth day — Re- 
mission — Relapse on the \6th; recurrence of the yellowness on the 
24^th, and abortion on the 25th day — a second Relapse on the 50th 
day. — Recovery. Treatment; castor oil, henbane, opium, (^c. 

Mrs Cox, Irish, aged 27, from the Cowgate, moderately stout, 
with dark hair, and light eyes, was 

Admitted, 29th September, {seventh day.) She is in about the 5th 
month of pregnancy, according to her own account. For some 
time past, she has not enjoyed good health. She states, that her 
husband, who is a labourer, has been out of work for the last ten 
months, and that the family has had insufficient aliment in con- 



HIGHLY CONGESTIVE FORM. 



77 



sequence. There were several cases of fever in the stair where 
she hved, before she took ill. 

On the 23d, she was seized with rigors, headach, pain in the 
back and limbs, anorexia, thirst, and weakness; and these symp- 
toms have continued, more or less, till admission. She felt rather 
better this morning, than she has done since her seizure. 

The pulse is 140, soft, and weak; the tongue is brown, and 
moist; there is a good deal of thirst; the bowels are open from 
medicine; there are flea-bites, with circles of ecchymosis around 
them, thinly scattered over the chest and abdomen; she has slept 
very little since admission; there is very severe headach; the in- 
tellect is clear; the expression of the countenance indicates suf- 
fering; there is bad taste in the mouth; she feels very weak; she 
has some cough, and slight uneasiness in the abdomen. — Abra- 
datur capillitiim^ et appUcetur aqua frigida toto capiti. 

SO fh Septemler^ {eighth day.) She slept very ill during the 
night, and the headach is not relieved. The head has not been 
shaved as ordered; and the cold water has not been diligently 
used. The pulse is 118, very feeble; the tongue is moist, and 
nearly clean; the bowels have not been opened since admission; 
there is a good deal of pain in the lower part of the abdomen. 
The movements of the foetus have been very feeble since her ill- 
ness; and she has not perceived them at all to-day. The dark 
abdominal line is broad, but rather indistinct. — Alradatur capilU- 
tium, et applicetur aqua frigida capiti. — Capiat olei ricini 5i, sta- 
tim. — Haheat haustum cum solutionis muriatis morphiw gtt. xxv^ 
hord somni. — Pu. tincturce hyoscyami Iss. Sumat gtt. xxv, eras 
mane, et repetatur si dolor sistat. 

2d October, {tenth day.) She has taken the henbane three 
times, and feels much better. There is a slight yellow tinge on 
the face, neck, chest, and abdomen, which is not perceptible on 
the legs. The bowels are open. — Quiescat. 

Sd October, (eleventh day.) There is some drowsiness, which 
seems to be caused by the henbane, which she has taken regular- 
ly. She looks much better; she complains of pains in the joints, 
with stiffness and soreness in the limbs on motion. The pulse is 
80, of moderate strength. There is no trace of yellowness ap- 
parent, except a scarcely perceptible tinge on the neck, and face. 



78 



HIGHLY CONGESTIVE FORM. 



— E. hydriodatis potassce 3^}', infusi gentiance gi'y, sumat 4;', forma 
haustus^ sexta qudque liord. 

4t/i October, (twelfth day?) The general pains are much better, 
and she feels in every respect more easy. She has taken two 
closes of the mixture prescribed yesterday. — Pergat. 

btli October^ {thirteenth day.) She is entirely free of the gene- 
ral pains; and there is a great improvement in her appear- 
ance. The pulse, tongue, and skin are natural. The bowels 
are confined. She has taken five doses of the mixture. — R. olei 
ricini li, aquw menthw solutionis ^nuriatis morphim gtt. xv. 
Fiat mistura, hord sojnni sumenda. 

8th October, (sixteenth day.) Since last report, she has been 
going on improving. — Quiescat. 

9th October, (seventeenth clay.) Last night, she was seized with 
headach, and subsequently, perspiration broke out. At present, 
the pulse is 100, and soft. She makes no complaint. — Quiescat. 

11th October, (nineteenth day.) She feels ill, and complains of 
pain in the abdomen, back, and thighs. The pulse is 98, soft, and 
of good strength. — Habeat haustum cum solutionis muriatis morphiw 
gtt. ccl, hord somni sumendum. 

. 12th October, (twentieth day.) There has been little, if any 
change, since the visit yesierdsiy.— Habeat tincturce hyoscyami gtt, 
XV, tertid qudque hord. 

ISth October, (twenty-frst day.) The improvement, since last 
report, is very decided; the pains have entirely left her. A 
very distinct dark stripe extends from the ensiform cartilage to 
the pubes. It is very much deeper than when last reported. — 
Omittatur tinctura hyoscyami. 

I7th October, (twenty-fifth day.) On the 15th, she had bear- 
ing-down pains occurring regularly at intervals, which abated 
towards evening, after the administration of a draught, contain- 
ing a drachm of the solution of the muriate of morphia. About 
half-past three o'clock this morning, they returned; and about 
four o'clock, a female foetus, apparently between the fourth and 
fifth month, was expelled. The placenta was retained, and had 
to be removed by the hand at 10 a.m., which was accom- 
plished with some difficulty, owing to the contraction of the 
uterus. At present, she feels easy. There has not been much 



HIGHLY CONGESTIVE FOBM. 



hgemorrhage. The pulse is 68. Yesterday, the yellowness re- 
curred in considerable intensity; it has rather faded to-day.— 
Habeat hzustum c. solutionis muriatis morpliice gtt. xl, Jiord somni 
sumendum. 

ISth October, {twenty-sixth day.) She is going on well. The 
yellowness has disappeared. — Quiescat. 

17th November, (fifty-sixth day.) She is now convalescent 
from a third attack, which she had on the 11th of this month. 

2Sd November, (sixty-second day.) Dismissed cured. 

Case XXII. — Summary. — Yellowness on the 9th day — Relapse on 
the \9th day, in which there was severe diarrhoea, (perhaps 
caused by colchicum,) and no yellowness. 

Margaret M'Intosh, Scotch, married, aged 61, from Steven- 
law's Close, of stout development, with iron-grey hair and blue 
eyes, was 

Admitted, 7th October, (seventh day.) On the 1st, she was- 
seized with pain in the back and limbs, slight headach, and shi- 
vering. The headach increased on the 8d, and has continued 
very severe since then. She attributes the present attack to ex- 
posure to contagion, as she has been in the habit of coming every 
night to see a daughter at present in this hospital. 

The pulse is 116, of moderate strength; the tongue is brown- 
ish, moist, and chapped; the bowels have been opened slightly 
to-day ; she gets no sleep ; the headach is severe ; the intellect 
clear ; the muscular power mnch depressed. — Habeat pilulam 
colocynthidis compositam. 

8th October, (eighth day.) She slept pretty well during the 
night ; her bowels have been opened by the colocynth pill ; the 
headach is severe ; the pulse and tongue are as yesterday. — 
Abradatur capillitiim, et applicetur aqua frigida capiti. 

9th October, (ninth day.) She has passed a bad night, owing 
to purging from a dose of castor oil, given about 10 p.m. by the 
nurse. She feels very weak to-day; the pulse is 1 1 6, weak, and 
tremulous; the tongue is white, and rather dry; there is distinct 
yellowness of the face, chest, and conjunctivae. — Habeat pilulam 
hydrargyri statim, hord somni, eras mane, et meridie. — Haheat vini 
rubri ^iv. 



80 



HIGHLY CONGESTIVE FORM. 



10th October^ {tenth da^.) The yellowness is the same as yes- 
terday; the tongue is chapped, dry, and inky-looking. — Habeat 
pilulam hydrargyria Jiord somni. — Continuatur mnum. — To haw 
cold heef-tea for drink. 

Wth October^ {eleventh day.) She looks, and feels better than 
yesterday; the bowels are confined. — Habeat olei ricini li statim. 

12th October, {twelfth day.) She feels much better than yester- 
day. The yellowness has in a great measure disappeared. — 
Quiescat. 

ISth October, {thirteenth day.) She feels much better, but com- 
plains of weakness. — Quiescat. 

19th October, {nineteenth day.) To-day, she has relapsed with 
considerable severity. 

20th October, {twentieth clay.) The skin is hot; the pulse is 100; 
the tongue is loaded with a white fur in the centre, clean, and red 
at the edges; there is excruciating general pain, which is so se- 
vere as to prevent her from turning in bed. — B. mni colchici ^ss^ 
tincturce opii Zij- Misce. Bumat guttas xv, ter in diem. 

25th October, {tiventyffth day.) The muscular and articular 
pains have left her. There is much diarrhoea, with tenderness of 
the abdomen, and griping ; the stools are liquid, and streaked 
with blood. — Injiciatur enema anodymm. — Haheat pilidam, acetatis 
plumbi et opii tertid qiidque hord. — Intermittatur mnum colchici. 

2^th October, {tic enty -seventh day.) The diarrhoea abated after 
six pills had been taken ; she is now free from pain, and much 
im^voNQdi. -^Quiescat. 

V7th November, {forty-eighth day.) She is much better now, 
but is weak, and complains of trembling fits, which seize her 
when she rises from bed. She states, that her life has been seve- 
ral times, (before entering the hospital,) in extreme jeopardy, from 
fits of purging. — B. sidphatis quininw gr. xxiv, extracti gentiance 
compositi q. s. ut fiant pilulce xij. Sumat unam bis in diem. 

26th November, {ffty-seventh day.) She is slowly regaining 
her strength ; but it is not yet considered safe to dismiss her from 
the hospital. Her only complaint is weakness. 



HIGHLY CONGESTIVE FORM. 



81 



Case XXIII. — Summary. — Yellowness in the first attack — Belapse 
on the 1 Uh or 1 Qth day^ accompanied with erysipelas^ livid patches^ 
and delirium^ followed hy parotid abscess^ and tedious Recovery — 
Treatment; stimulants^ S^c, 

Janet Baillie, aged 70, married, residing in Borth wick's Close, 
was 

Admitted^ 2d August, along with her husband. She was treat- 
ed by Dr Craigie, from the time of admission, till I took charge 
of the Hospital on the 10th, when she was found convalescent 
from a pretty severe attack, in which there had been jaundice. 
From the great pressure of cases, it was not attempted to take 
the history of all those under treatment; and unfortunately, 
Janet Baillie was not one of those selected for minute observa- 
tion, and reporting. The notes extant of her case are very scanty. 

She relapsed on the 15th or 16th day of the disease; on the 
2d day of it, she had congestive delirium, involuntary passage of 
the stools, and urine, erysipelas of the face and scalp, livid patches 
on the back and limbs, and subsequently, the formation of an im- 
mense parotid abscess, which rendered the recovery very tedious. 
The quantity of wine, whisky, and other stimulants, which 
she consumed, was much greater than that used by any other 
patient, treated by me in the New Fever Hospital. Her reco- 
very also, it may be added, was quite unlooked for. The treat- 
ment consisted in cautious purging, the free use of stimulants, 
and topical applications for the erysipelas. 

Her husband had a severe attack, but of a different kind; he 
had no well-marked remission, and his case was very similar to 
the ordinary continued fever of Edinburgh, although no erup- 
tion was noticed. 

Case XXIV. — Summary. — Admission on the 15th day, leing 
the 1st of his Relapse — Yellowness, urgent hiccup, and vomiting. — 
Hare soup vomit. Treatment ; opium, creasote, and wine. Re- 
covery. 

J ohn Conway, aged 60, an Irish labourer, single, in Edinburgh 
only for one day, and just arrived from Dunbar, was 

Admitted on the 9th October, (fifteenth day.) On the 25th 

M 



82 



HIGHLY CONGESTIVE FORM. 



September, he was seized with headach, shivering, and pains in 
the back. He seems to have passed through the first attack, 
and to be now entering on the second. 

The pulse is 84, and of moderate strength; the tongue is 
clean; there is much thirst; the bowels are confined; he com- 
plains of sleeplessness, intense headach, and a bad taste in the 
mouth; he has severe hiccup, much muscular depression, and 
bronzing of the countenance. 

lOtk October^ (sixteenth day.) The hiccup is much moderated; 
the pulse, and skin are natural. 

\1th October^ {eighteenth day,) Severe hiccup, and vomiting 
distress him. 

12th October^ (nineteenth day.) The hiccup, and vomiting are 
very annoying. Sinapisms have been repeatedly applied. 

\5th October^ (twenty-first day.) There is less hiccup, but he is 
excessively depressed. Opium, and creasote mixture have been 
the medicines employed to check the vomiting, but they have 
produced no benefit ; he has taken eight doses, of one ounce 
each, of the creasote mixture, and several grains of opium, in the 
form of pill. — Habeat mni rubri ^vi. — B. opii puri gr. conserves 
rosar. quantum suff. ut fiat massa, in pil. x dimdenda. — Sumat 
unam, secunda qudque hord. 

1 Qth October^ (twenty-second day.) Yesterday, when under the 
narcotic influence of the opium, the hiccup and vomiting were mo- 
derate; he slumbered much, but had no refreshing sleep. To-day, 
he has vomited a good deal; the matter ejected seems to be the 
ingesta unaltered. He has no vomiting, except after eating or 
drinking; and every thing he swallows is immediately rejected. 

October^ (twenty-fourth day.) The hiccup seems to be gone; 
he is lying tranquil; he has taken all the pills. During last 
night, he awoke from slumber, and vomited, without pain or strain- 
ing, a large quantity of fluid, resembling hare soup in colour and 
consistence. It consists of a supernatant fluid, with a sediment 
of black particles, resembling coarse oatmeal in all their phy- 
sical characters, excepting colour. He seems better than h© 
has been for some days; but the nurse states, that this favour- 
able change has only occurred within the last hour. A faint 
yellowness is perceptible upon the face, chest, abdomen, supe- 
rior extremities, and thighs. 



HIGHLY CONGESTIVE FORM. 



83 



20th October, (twenty-sixth day.) There has been great improve- 
ment, since last report; the countenance has exchanged its yel- 
low, for a leaden colour. He has taken one or two opium pills; 
and the nurse has instructions to administer them at short inter- 
vals, should the vomiting recur. 

10th Noxiemher, {forty- seventh day.) After last report, the irri- 
tability of the stomach gradually subsided; and he is now dis- 
missed in perfect health. 

The above reports comprise all the yellow cases treated by 
me, in the New Fever Hospital, except a very few slight ones, 
which not having been regularly reported, are only placed in 
the tabular views. From the tables it will be seen, that in many 
cases, epistaxis occurred, and in some profuse menstruation. 

A number of interesting yellow cases have occurred to me, 
since I entered upon the charge of my wards in the Royal Infir- 
mary; and an account of some of the more malignant of them 
are added in the Appendix. 



84 



PATHOLOGY OF THE DISEASE. 



CHAPTER III. 

PATHOLOGY OF THE DISEASE. 

The present epidemic possesses positive, and negative characters^ 
strikingly distinguishing it from the fever which generally pre- 
vails in Edinburgh, viz. — 

1 . The sudden and molent invasion of the disease. 

2. Bronzing^ leadening^ or purpling of the countenance hefore and 
after seizure, 

8. The almost uniform occurrence of one or more relapses. 

4. The unusual number of cases with yellow skin, black vomits 
and hemorrhage. 

5. The short duration of the pt/rexial state, and its mode of ter- 
mination. 

6. The severe muscular and articular pain. 

7. The rosy, elliptical eruption resembling measles is absent in al- 
most every case in the present epidemic. 

Whilst these are the principal characters which distinguish 
the two epidemics, they also exhibit other marked differences; 
for instance, in that which now prevails, 

8. Severe vomiting is much more common; as are likewise gastric, 
gastro-hepatic, gastro-splenic, and g astro-enteric symptoms. 

1 . The sudden and violent invasion of the disease. 

In this, the present epidemic resembles that which prevailed here 
in 181 7-20. Dr Welsh says, in his description of that fever, — " Fre- 
quently, the persons affected continue at their usual employment for 
some days, with languor, lassitude, aversion to motion, and loss of 
appetite ; there are, besides, transient slight chills and flushings, 
after which, they are attacked with decided rigors, pain of the back, 
and other symptoms of fever. More generally, however, the at- 



PATHOLOGY OP THE DISEASE. 



85 



tack is sudden, the patient feeling previously no unusual sensation : 
sometimes, when at work, or getting out of bed, to which they had 
gone in perfect health the preceding evening; or, in short, after 
any unusual operation, they find themselves attacked with severe 
rigors, headach, pain of the back, nausea, ajid sometimes vomiting, 
or diarrhoea."^ 

The present fever comes on even more suddenly, than that de- 
scribed by Dr Welsh, which, however, we learn from his narra- 
tive now quoted, seized the patients much more unexpectedly, and 
far less insidiously than the true typhus, which of late years has 
been most familiar to us in Edinburgh; and a faithful account of 
which is given by Drs Henderson and J. Reid, in No. 141 of the 
Edinburgh Medical and Surgical Journal. 

I have not found, that my patients described the attack as fol- 
lowing " any unusual operation," and many of them stated, that 
they were taken ill, when engaged in their ordinary routine of 
domestic, or other occupations, lounging, eating, or sitting at the 
fireside. 

From what I have seen, and read of the manner of the invasion 
of typhus fever in various epidemics, I regard the sudden and 
violent invasion of the present fever as characteristically diffe- 
rent from the way in which that disease sets in. 

2. Bronzing^ leadening, and purpling of the countenance before and 
after seizure? 

This, as has been already mentioned, is to the visitor of our fever 
wards, one of the most remarkable peculiarities of the prevailing 
epidemic. Dr Maclagan upon one occasion remarked to me, upon 
entering oneof my wards, that the bronzed countenances all around, 
strongly reminded him of the military hospital of which he had 
charge during the Walcheren epidemic. Others, again, familiar 
with the remittents and intermittents of Canada, the West In- 
dies, and Italy, have assured me, that the facial bronzing bore 
a strong resemblance to what they have seen in persons affected 
with them in these countries. The more marked cases of bronz- 
ing brought to my own recollection the aspect of the inhabitants 

' On the Efficacy of Bloodletting, in the Epidemic Fever of Edinburgh. By Ben- 
jamin Welsh, M.D. Edinburgh, 1819. 8vo, p. 16. 
» Vide Cases XIX. and XX. 



86 



PATHOLOGY OF THE DISEASE. 



of such marshy districts of Italy, as the Pontine marshes, and 
the unwholesome swamps around the ruined temples of Psestum. 

Here also, there exists an interesting point of resemblance be- 
tween the yellow fever of hot countries and our present epidemic. 

The authors who have described yellow fever with most minute- 
ness, mention a peculiar change in the colour of the countenance 
before it assumes the yellow cast. Audouard, in describing the Bar- 
celona epidemic of 1821, pictures to the very life the way in which I 
have seen the yellowness come on in our present fever — the dingy 
bronzing or leaden hue as it were sliding into the yellow.^ On the 
5th day, he says, — " La face est de couleur plombee, tirant sur le 
jaune, et le tour des yeux legerement ecchymose; le globe de Toeil 
est plus jaune et moins rouge que la veille; le regard fixe et hebete, 
d"* autres fois inquiet."^ Blane, in describing the yellow fever, 
which he observed, evidently refers to something very similar to 
what was noticed in my cases. " There is something," sa3^s he, 
very peculiar in the countenances of those who are seized with 
this disease, discernible from the beginning, by those who are 
accustomed to see it. This appearance consists in a yellow, or 
dingy flushing, or fullness of the face and neck, particular- 
ly about the parotid glands, where the yellow colour of the skin 
is commonly first perceived."^ 

8. The almost uniform occurrence of one or more relapses. 
Dr Oraigie, in a paper on the present fever, which he has pub- 
lished in the Edinburgh Medical and Surgical Journal, says, — 
; *' The proportion of cases in which relapses or second attacks take 
\ place, is very considerable, so great indeed, that several observers 
believed, that they occurred in all the cases. I find, that from 
accurate accounts, kept of 182 cases, in 110, relapses had taken 
place, which is equivalent to 60| per cent, exactly.*" My expe- 
rience differs widely from this statement of Dr Craigie, and 
leads me to say most confidently, that unless anti-periodic re- 
medies are employed, one or more relapses will occur, with 
hardly a single exception ; and further, that it is only in a limit- 

^ This peculiar appearance is so characteristic, that of late, I have predicted with 
unerring accuracy the appearance of the yellowness before a trace of it existed. 

2 De la Fievre Jaune que a regne' a Barcelone, en 1821, par M. F. M. Audouard, 
D.M.M. P. 60. Paris, 1822. 

^ Blane on the Diseases of Seamen,. 3d Edition. London: 1799 p. 419. 



PATHOLOGY OF THE DISEASE. 



87 



ed number of instances, that these medicines act as preservatives 
from relapses. A large number of the patients who have come 
under my care, have been dismissed as cured from the wards of 
the Royal Infirmary, and Fever Houses. Others again, of my 
own patients have had second, third, and fourth relapses at home, 
or in hospital, after leaving my wards. This generally happened in 
persons who had been dismissed at their own request, or sent out 
in consequence of the urgent demands made for admission, in be- 
half of severer cases. The same causes must of course have com- 
pelled Dr Oraigie to dismiss from his wards many persons, who, had 
they remained longer under observation, would have swelled his ca- 
talogue of relapses. Be that as it may, I have hardly seen a single 
case, which has been under careful observation, between the thir- 
teenth and eighteenth day of the disease, which has not had a re- 
lapse during that period : — a period of the disease within which a 
great number of dismissals have been made by other physicians, 
and occasionally by myself, though always with reluctance. The 
facts now stated explain satisfactorily the apparent discrepancy 
between my statistics, and those of Dr Craigie, which bear upon 
this point. 

In reference to the same subject, Dr Craigie further remarks: 
" A third attack of febrile symptoms has been observed in a very 
small proportion of cases, I think not more than three in 346 
cases, or less than one per cent. These third attacks were more 
frequent in Glasgow." Here again, my experience does not ac- 
cord with that of Dr Craigie. Third attacks I have found to be 
exceedingly common; fourth attacks not very uncommon; and 
several instances have occurred, to my knowledge, of patients 
having a fifth attack.^ One person was admitted under my charge 
into ward No. 6, in the Royal Infirmary, who had gone through 
three attacks in hospital before becoming my patient, two of them 
under Dr Craigie, and one of them under Dr Henderson. The 
fact is, that it is quite impossible to give correctly the statistics 
of the relapses, upon a large scale, so migratory are the patients 
between hospital physicians, dispensary doctors, and practising 
druggists. I have seen enough, however, to convince me, 

' A man named Bird, whom I left in the New Fever Hospital, recovering from 
a second relapse, died there, the other day, exhausted after a fourth relapse or fifth 
attack. 



88 



PATHOLOGY OF THE DISEASE. 



that second attacks occur almost uniformly, and that one or more 
subsequent relapses are far from uncommon. 

Dr Welsh, speaking of the relapses which occurred in the epi- 
demic of 1817-20, says, that relapses occurred in one-fifth of the 
whole cases, but it also appears from his work, that in this state- 
ment, the relapses only are included^ which took place when the 
patients were under his own observation, in Queensheny House 
Hospital. But even at Dr Welsh's estimate, the frequency of 
relapses in the fever which he describes, is sufficient to point out 
in this particular, another feature of strong analogy between it 
and that now prevailing. The recurrence of the attacks, though 
occasional in typhus, is rare, and can most commonly be traced 
to errors in diet, or some other indiscretion. Independent of any 
accidental exciting cause, the relapses take place in the present 
fever. 

4. An unusual number of cases exhibiting yellow skin, black 
wmit, and hcemorrhage. 

In the cases which I have reported, and also in those which 
I have treated since going to the Infirmary, these symptoms 
occurred very frequently. Dr Welsh tells us, that in the 
] 81 7-20 epidemic, " a yellowish or husky state of the skin 
was not unfrequently observed, but did not appear to be dis- 
tinctly referable to any particular state of the liver, or other 
viscus, farther than the diffusion of bile among the different 
fluids usually indicates; for that such difiusion had actually 
taken place, appeared to be verified in all the cases of yel- 
low skin in which any trials were made. In all of these, the pa- 
tients' urine distinctly tinged linen cloth, or similar substances, 
immersed in it." P. 21. In another part of the same work, he 
says, " decided yellowness of the skin and eyes occurred in twen- 
ty-four patients, or one in 30|f ; and in all these cases, where the 
experiment was tried, the urine tinged linen. This symptom was 
observed in 4, or 1 in 8J of the fatal cases.'' It appears then, 
that the present epidemic resembles that of 1817-20, in the fre- 
quency of the yellow cases. I have been told by several friends 
who had experience of that fever, that the yellow cases occurring 
at present are much more malignant, than those which were seen 
in it. 



PATHOLOGY OF THE DISEASE. 



Yellowness and black vomit have, by most writers, been taken 
as characters of special disease; and we find remittent and con- 
tinued fevers, when prevailing epidemically, each described under 
the designation of yellow fever. A very cursory, if judiciously 
directed study of the literature of this disease, will convince any 
one, that the term " yellow fever" is applied to fevers differing 
essentially from one another in their character, constitution, and 
mode of propagation. Four years ago, I visited Barcelona, 
Gibraltar, Cadiz, and other towns of the Mediterranean, where the 
epidemic prevailed, described as yellow fever by Moreno, Louis, 
&;c., and conversed with the physicians most conversant with the 
disease; and I never heard from one of them, as I find on re- 
perusing my notes, any diagnostic characters of the fever, except- 
ing the yellow skin and black vomit ; though, in a majority of the 
fever cases occurring at that time, these symptoms were not 
seen. In ordinary conversation, the term may be allowed, 
but it ought to be banished from the scientific nomenclature of 
disease, inasmuch as yellow skin, and black vomit, black stools, 
and urine, and haemorrhages, are consequences of congestion, 
liable to occur in fevers of all types, and countries. A few illus- 
trations of this statement may be desired. They are there- 
fore subjoined : 

Dr Ohristison, in his work on Continued Fever, contained in 
the Library of Medicine, mentions "disorder of the hepatic sys- 
tem, accompanied with jaundice," as " an important, though rare 
complication." He says, that " it occurs chiefly in the autumn 
months, and principally in those epidemics, where the inflamma- 
tory type is prevalent. Yet it is important, because cases where 
it occurs commonly prove fatal. The exact nature of the affec- 
tion is not apparent. The symptoms are rapidly formed jaun- 
dice, sickness, with frequent vomiting, but without particular un- 
easiness in the region of the liver, extreme prostration of strength, 
much tendency to coma at an early period of the fever, speedy 
sinking of the pulse, and in general, bilious stools. The symp- 
toms show themselves in the course of the first week. If they 
do not begin to abate in two or three days, death occurs in a few 
days more, under a state of extreme exhaustion, and deep coma. 
Should the yellowness of the skin, however, begin to diminish, the 

N 



90 



PATHOLOGY OF THE DISEASE. 



other secondary symptoms soon subside also, and the fever runs 
its usual course. Some have imagined this affection to be allied 
in nature to the yellow fever of hot countries, but with what jus- 
tice it is not very easy to say."'^ 

On the 7th of June 1843, Mr Henry D. S. Goodsir, of An- 
struther, communicated to the Medico-Chirurgical Society of 
Edinburgh, a paper, entitled '^Account of a Form of Continued 
Fever, accompanied hy Jaundice, wliicli occurred in the Eastern 
District of Fife in 1841-42; with some Observations on the Gastro- 
intestinal Character of the Endemic Fever of that District. '''' 

The prevaihng type of the fever in that district differs from 
that of Edinburgh in its symptoms, and anatomical characters. 
The patients generally suffer from tympanitis and abdominal 
tenderness; and on dissection, are found ulceration, and occa- 
sionally perforation of the mucous membrane and glands of 
the intestinal tube: " Up to the year 1840, the symptoms and 
dissections indicated, that the local complication was confined to 
the solitary and aggregated glands of the ileum and coecum. In 
1841 and 1842, the disease, although still exhibiting the same 
mode of origin and propagation as in the more ordinary forms of 
continued fever, was almost always accompanied by jaundice, 
(occasionally very dark), urgent thirst, irritability of stomach, 
copious secretion of mucus in the throat and mouth, pain in the 
epigastric and right hypochondriac regions, obstinately confined 
bowels, with acute and continued headach. The pains which 
ushered in the disease were more distressing than usual, and 
were confined more to the joints, which generally became slightly 
swollen. After the skin had become yellow, the urine became 
deep, and the stools pale in colour, the skin itchy, with some de- 
crease in the severity of the other symptoms. The pulse ranged 
from 100 to 150. There was generally, as in other forms of 
continued fever, more or less severe bronchitis.'' 

A case of typhus came under my observation, in one of Dr 
Alison's fever wards, at the time when I was engaged as his 
clinical assistant, in which the patient, on the seventh day of the 
fever, after a well-marked remission of the symptoms (which had 

' Christison. Article, Con^inweJ i^ever, iu Library of Medicine. Loudon: 1840, 
p. 140. 



PATHOLOGY OF THE DISEASE. 



91 



been severe) was suddenly seized with jaundice, and black vomit. 
About 5 p*M., he took some whiffs of tobacco smoke from the 
pipe of a convalescent patient.^ Shortly after this, he fell asleep, 
and awoke with a fit of vomiting, and pain in the abdomen. For 
twelve hours after this, he had incessant vomiting of black mat- 
ters, and some epistaxis; at the end of which time he died unex- 
pectedly in convulsions. Upon dissection, the bile-ducts were 
found to be pervious, and the liver healthy. The only other ap- 
pearance which I have noted of this case, is, that the vena cava 
and heart were enormously distended with fluid, and frothy blood, 
a circumstance which, at the time, particularly arrested my atten- 
tion, as the dissection was made within thirty hours after death, 
and during the intense cold of January 1888, with the thermo- 
meter below 20° Fahr. During the whole course of the case, the 
temperature was below the freezing point.^ 

What have been termed by some, sporadic cases of yellow fever, 
were seen in Paris, after the hot summer of 1822, which we 
are informed by Andral, were decidedly typhoid. In the autumn 
of that year, several cases of fever, accompanied with yellow skin 
and black vomit, occurred in the Hotel Dieu, and at the same 
time two patients were similarly affected in La Charite.^ 

Dr Stokes, in the article Enteritis in the Cyclopaedia of 
Practical Medicine, and Dr Graves in his Clinical Medicine, 
describe some cases of yellow fever which they treated in the 
Meath Hospital of Dublin, during the epidemic of 1827. The 
latter gentleman, in introducing the subject to his pupils, re- 
marked, that " there is not so much difference between the dis- 
eases of Ireland and warmer countries as has been imagined. 
They differ, it is true, as to their degrees, but not as to their pa- 
thology."* Were this doctrine more generally appreciated, the 
accounts of the different fevers unfolded to us, in the oral and 
written compilations of our preceptors, and of what are termed 
systematic writers, would perhaps present less picturesque and 
piquant, but certainly simpler, and truer pictures of disease. 

1 The use of the pipe in the wards is contrary to rule. 

2 This case is referred to in my second pamphlet on Air in the Veins, entitled, 
Remarks on a Case of Suicide, &c. Edinburgh, 1838. 

^ Andral. — Article Typhus, Dictionnaire de Medeciue. 
* Graves.— CHnical Medicine, 8vo. Dublin, 1843, p. 215. 



PATHOLOGY OF THE DISEASE. 



In proceeding with tlie notice of the Dublin yellow fever, it 
may be first remarked, that in fifteen cases, Dr Graves could 
detect no difference in the symptoms which they presented, and 
those which characterize tropical yellow fevers. I quote the pa- 
rallel which he draws, in his own words : — 

" Is^, In both, patients become yellow, from absorption of bile 
into the system ; but observe, in epidemics of yellow fever, it 
never happens that all, or even most of the cases, turn yellow. 

" 2d, These yellow cases are here equally fatal. 

" Bd, Tenderness of the epigastrium and vomiting were pre- 
sent in both. 

" 4ifh, The strongest die. 

" oth, Jaundice does not depend on hepatitis in either. 

" 6t/i, Nor on any permanent obstruction of the gall-ducts. 

*' 7th, In both, the seat of the disease is a violent inflammation 
of the mucous membrane of the stomach and duodenum ; dark 
purple, soft, and semifluid. 

Stii, Black vomit in true yellow fever consists of a sanguine- 
ous fluid mixed with the vitiated secretion of the stomach and 
blood, this forms the coffoe grounds. This Mack mmit we found 
in one of our patients'* stomachs." 

The statement, that violent inflammation of the mucous mem- 
brane of the stomach and duodenum is in both the seat of the 
disease, is, we must remember, an opinion, and not an acknow- 
ledged fact; but then, the observation that the mucous membrane 
of this part of the intestinal canal was found dark purple, soft, 
and semifluid, is of high value, being the record of physical ap- 
pearances actually seen, and not matter of theory, but of history. 
In the yellow cases of the fever now prevailing in Edinburgh, 
this same altered state of the gastro-intestinal mucous membrane 
is found ; but there is no lymph eff'used — nothing, in fact, indi- 
cative of inflammation, unless in some severe cases which linger 
long; in such I have seen inflammation around effused clots of 
blood, which seemed to have been the cause of this, — just as any 
other foreign body might act.^ In my cases, also, the gall-ducts 

' This observation is founded upon cases which I saw examined in the Infirmary, 
since the first part of this tract was printed. 



PATHOLOGY OF THE DISEASE. 



93 



were found pervious, and indeed, in all respects, the correspondence 
was complete between the symptoms of my cases, and those con- 
sidered by Dr Graves common to the yellow cases which occurred 
in Dublin in 1829, and the yellow fevers of tropical climates. My 
cases differ in being remittent, in place of continued, just because 
the epidemic at present prevailing here is of the former, whereas, 
that which ravaged Dublin, when Dr Graves' cases occurred, was 
of the latter type. 

Two of Dr Graves' cases are subjoined, to afford the reader 
the means of understanding the exact nature of the group. 
The observations which he appends to each are also given. 

" John Gaven, aged 22. — This man's case differed in no mate- 
rial circumstances from the preceding oases.— Dissection^ twenty 
hours after death. Body extremely well made, strong, and mus- 
cular. Nothing morbid in head or thorax, except dilatation of 
some bronchial tubes. There were five intus-susceptions in the 
small intestines, without any adhesions or marks of recent in- 
flammation ;^ other parts of the intestines are considerably con- 
tracted ; the mucous membrane of the stomach, from the cardiac 
orifice, to within about two inches of the pylorus, is of a brownish 
red colour. Here, the mucous membrane yields readily to the 
back of the knife, and may be scraped off in a semifluid state ; it 
contains several patches of ecchymosis. The whole of the intes- 
tinal tube, with the exception of the duodenum, and the lower 
half of the larger intestines, has its mucous membrane of a dark 
red colour, with numerous ramifications of vessels engorged with 
blood. In many parts, the m.ucous membrane is very soft, and 
almost semifluid. The liver is perfectly healthy, and there is no 
obstruction in the gall-ducts. 

" Ohservations. — As our limits will not permit us to detail more 
dissections of this truly curious and fatal form of fever, we shall 
merely sum up some of the principal points connected with its 
pathology. \st, In none did we find inflammation of the liver or 
obstruction of the gall-ducts. 2d, In all, evident marks of in- 
flammation ( i) were found in the mucous membrane of the sto- 

» I never met with intus-susception so frequently mentioned by Dr Graves in the 
details which he gives of his yellow cases. It is sometimes noticed in tropical yeUow 
fever. 



94 



PATHOLOGY OF THE DlSEASEfi 



mach, such as redness, softness, &c. Sd^ In almost every in- 
stance, we found one or more intus-susceptions in the small in- 
testines. 4ifA, All these were without any mark of inflammation 
of the serous membrane, and the invaginated portion of intestine 
could always easily be drawn out of the other. 5th^ In several, we 
found effusion of a yellowish or amber-coloured fluid between the 
arachnoid and pia mater, at the base of the brain, and sometimes 
in the ventricles, but in these only in small quantity. 6t/i, In 
none, did we find inflammation of the brain or its membranes. 
7th, We have found the spleen very much enlarged in almost all. 
When the spleen in acute cases is thus engorged and distended, 
it is invariably softer than natural. In but one case did we find 
a considerable quantity of a dark red fluid in the stomach, to- 
gether with a good deal of a substance resembling coffee grounds, 
and in this case, the mucous coat of the stomach was in many 
places of a very red colour, and a slimy consistence, so that there 
could be but little doubt concerning the origin of the contained 
fluid and the coffee-ground substance, which must have proceeded 
from the diseased, and almost disorganised mucous membrane. 
Such have been the principal appearances observed during the 
dissection of about fifteen fatal cases of fever, combined with yel- 
lowness of the skin. The following cases will convey a more exact 
idea of the symptoms which characterise this form of fever than 
those already related, which proved too suddenly fatal to allow a 
full development of the symptoms. 

" Peter Kelly, aged 28, — on the 29th December, was ad- 
mitted into No. 4, fever shed, stating, that for two days pre- 
viously, he had had severe cough without expectoration. Pulse 
110, strong; face flushed; tongue white, and moist; pain across 
forehead, and general distress; great tenderness of epigastrium, 
and right hypochondrium ; costive; thirsty; abdomen hard: on 
examination, no morbid rale was perceptible; the respiratory 
murmur was natural. — SOth December. Veneseciio ad dccv. — 
Hirudines xx epigastric . — PiLpurg. et mist, pur g. — Sls^ December. 
Cough very severe. — Vesicatoriiim p)ectori. — Mist, pectoralis. — 1st 
January 1827. During last night, he became jaundiced; consider- 
able distress this morning; black stools; great tenderness of epi- 
gastrium and right hypochondrium; cough very troublesome. — 



PATHOLOGY OF THE DISEASE. 



95 



Venesectio ad ^xij. — Hirudines xwx, hypochondrio et epigastrio. — 
Ahradantur capilli, et appUcetur vesicatorium verfici. — Sumat omni 
hord^ calomelanos gr. ij. — 2d January. Much relieved; skin not 
nearly so yellow; tenderness greatly diminished; some sweat last 
night. — Bep. pilulw. — Zd January. Considerably improved; skin 
nearly natural. — 4ith January. Mouth affected with mercury; skin 
natural. — Omittantur medicamenta. — btJi January. Removed to 
convalescent ward. — ItJi January. Convalescence continues; ligis 
now no complaint, but of slight soreness of the mouth. 

" Observations. — Here the yellow colour appeared about the 
fifth day, and there was sweat attended with much relief on the 
seventh day. The symptoms chiefly worthy of notice are the vio- 
lence of the febrile reaction, pains of the forehead, great tender- 
ness of the epigastrium and right hypochondrium; blackness of 
the stools, and hardness of the belly. We shall just now see the 
great importance of these symptoms in determining the true na- 
ture of the disease." Pp. 206-208. 

In certain circumstances, traumatic fever assumes all the cha- 
racters of yellow fever. 

Larrey mentions that many of the wounded of the French 
army at Cairo and Alexandria, were cut off by a fever marked 
by jaundice and black vomit. 

Professor Sir George Ballingall, in a published Clinical Lec- 
ture,^ delivered at Edinburgh in 1828, describes and illustrates 
this variety of traumatic fever, in a most interesting and instruc- 
tive manner. The passage to which I refer is valuable, as tend- 
ing to establish a point which I am anxious to make out, viz. that 
yellow skin and black vomit are not specific, but accidental cha- 
racters of a fever. 

In the passage referred to, Sir George remarks, — One symp- 
tom, however, appeared early in this patient's case, which I did not 
fail to remark to my colleagues, and which, as far as my observa- 
tion goes, is a circumstance almost uniformly foreboding a fatal 
termination; I allude to a peculiar yellow hue of the skin, which 
not unfrequently attends the symptomatic fever supervening upon 
wounds and operations; this has perhaps struck me more for- 

^ Quarto, Edinburgh, 1828, p. 



96 



PATHOLOGY OF THE DISEASE. 



cibly, from being familiar with a similar appearance in the idio- 
pathic fevers of tropical climates ; and although I have no wish 
to alarm the citizens of Edinburgh, by talking of a yellow fever 
in this part of the world, yet I am bound to state, for your in- 
struction, that I have occasionally seen it here as well marked 
as I ever saw it at Seringapatam or Batavia, and, when super- 
vening upon injuries, much more uniformly fatal. 

" A case of this kind occurred some years ago, which made a 
deep impression on my mind, and which must have done so, I 
think, upon all those who had occasion to witness it; I allude to 
that of a seaman belonging to one of her Majesty's ships, in the 
roads, whose limb had been amputated below the knee, in conse- 
quence of an accident. The accommodation on board his ship 
being defective, and the vessel about to sail, he was brought 
ashore to this hospital, and placed under my care; here his 
stump sloughed, the symptomatic fever ran high, was attended 
with that dinsfv yellowness of the skin to which I allude, and in 
a few days he died. I observed to a surgeon of the ship who 
came ashore to see him dissected, that this case wanted nothing 
but the ' black vomit' to constitute a complete example of yellow 
fever; and it was found, on laying open the stomach, that this 
circumstance, necessary to complete the parallel, was hardly 
w^anting; for here was a large collection of dark grumous fluid, 
resembling coifee grounds, which is so often evacuated from the 
stomach in tropical fevers.'"* 

Yellow fever has frequently broken out in ships in warm lati- 
tudes, as in our vessels in the Carribean Sea, and on the coast of 
Africa. When this occurs in harbour, it may, and often no doubt 
has been owing to the miasmatic influences there prevailing; but 
when we see the disease suddenly breaking out in a ship far from 
land, and when there has been no communication during the 
voyage, with any vessel or town where the fever was at the time, 
since leaving the Thames, or any other healthy port, then we 
must look for some other cause than contagion or marsh mias- 
mata. In such cases, it has generally been remarked, that the 
ballast had been altered, or the hold rummaged for some par- 
ticular purpose. This would obviously cause putrid miasmata to 
ascend through the ship. The stench and putrid odour on such 



PATHOLOGY OF THE DISEASE. 



97 



occasions is often terrible ; nor is this to be wondered at, when 
we reflect upon the corrupted water, dead rats, and decayed ani- 
mal and vegetable matter of all kinds, which is too often allowed 
to accumulate in the holds of vessels, and allowed to rot there 
unmolested for years. 

Forget states in his Medecine Navale^ (torn. ii. p. 197), 
that two French war brigs, a schooner, and a frigate, when 
cruising off the Antilles, changed their ballast, and that mi- 
mediately, all of these vessels lost men from yellow fever. The 
Bedford, an English 74-gun ship arrived in Gibraltar Bay, in 
1794, from the Mediterranean, with all hands on board in per- 
fect health. In the course of one week, "after the shipping 
of the shingle ballast," ISO men were in the hospital affected 
with yellow fever. The disease was not prevailing at the time 
in the garrison, and no one attributed the visitation to contagion. 
Very few naval surgeons are contagionists, which is probably, in 
a great measure, to be attributed to their having had experience 
of such occurrences, as those we have now given examples of. 
Griffits of Philadelphia, designates yellow fever the ship fever of 
tropical climates. Dr Thomas Parke thinks that yellow fever may 
be produced by the morbific effluvia proceeding from the bilge 
water of vessels, — because, since 179S, he has always seen this 
disease commence at Philadelphia, near Delaware, and gradually 
extend to the w^est.^ 

The yellowness of the skin in yellow fever has been ascribed 
to general ecchymoses, and possibly, in some instances, it may 
originate in this cause ; for Andral has shown, that it is this 
which produces the saffron colour of the skin, in what is impro- 

' Hippocrates mentious a fever, which, from the symptoms mentioned, there is 
great reason to believe, was identical in its nature with some of the epidemics of 
yellow fever of modern times. In various passages, he speaks of the hlack vomit, 
which he regards as a mortal symptom; and in one place, he mentions a remittent 
fever, which he considered bilious, as raging in the Isle of Thasus, after a long 
continuance of hot weather. The patients were affected with nasal htemorrhages 
and severe pains, and generally about the fifth day the skin became yellow. 

In the Definitiones Medlcce, ascribed to Galen, there is a species of fever mentioned, 
called iKTi^uh'/is, in which the leading symptoms are said to be dry tongue, enlarged 
liver, and an exceedingly yellow skin. Some have supposed that the plague of 
Athens, described by Thucydides, and the morbus niger of the ancients, as well as va- 
rious other pestilences of former times, were identical with what we call yellow fever. 

0 



98 



PATHOLOGY OF THE DISEASE. 



perly called the jaundice of new-born children. I have noticed 
that in my cases, the yellowness was always most intense when 
the blood had been drawn to the surface by blisters, synapisras, or 
other means. However, if this explanation be adopted in regard 
to yellow fever, it can only apply to those cases in which the yel- 
lowness is partial, or limited to particular parts of the body. 
Moreno, Grillkrest, and others, have seen the sheets stained yel- 
low with the perspiration; and this we could hardly expect, were 
it merely ecchymoses which discoloured the skin. Moreover, 
(as in the present epidemic), the fluid in the cavities, and the 
urine, have often a yellow tinge; and John Hunter states,^ that 
the latter stains linen rags yellow, like that of a person in the 
jaundice. Fordyce attributes the yellow skin to a redundant 
secretion of sebaceous matter. Saunders believed that it de- 
pended rather "upon a particular state of the lymph in the cellu- 
lar substance of the parts, than upon the absorption of bile into 
the circulating mass."^ The most rational explanation seems to 
be, that it is the result either of an absorption of bile, or of its 
non-elimination from the blood. Ther© may be instances in 
which the former is the cause ; but when we remember the dis- 
ordered state of the secretions, and the diseased condition of the 
blood, it seems more natural to conclude that the bile has either 
not been secreted, or secreted in very small quantity. 

The bite of a particular kind of viper possesses the remarkable 
property of causing the skin to become deep yellow, and that some 
times, within the space of an hour. To produce this effect, how- 
ever, the poison must be in a concentrated form, and actually 
introduced into the circulation. The primary effect, both of the 
poison of the yellow fever, and of the bite of the viper, seems to 
be upon the blood ; and in both instances, there is a partial or com- 
plete suppression of the secretions. As intimately connected with 
this subject, it may be mentioned, that yellowness of the skin, yel- 
low sweats and yellow urine, have ensued from eating certain kinds 
of poisonous fungi and fishes; and it may also be stated, that 
there is a remarkable resemblance in the effects produced by the 
poison of animal and vegetable putrid matter, and the poison- 

' Observations on Diseases of the Army in Jamaica, p. 72. 
3 Saunders on the Structure and Diseases of the Liver, p. 104. 



PATHOLOGY OF THE DISEASE. 



99 



ous principle of certain fishes and fungi. Thomas states, that 
from the effects of the fish poison, he has seen the whole body 
become yellow, and the urine and sweat assume the same hue, 
the latter giving a deep yellow tinge to linen. He observed these 
symptoms in several cases ; and particularly in himself from eat- 
ing the pirea marina, a poisonous rock fish. The resemblance 
between the post-mortem examinations in cases of poisoning from 
fungi, to those detailed as characteristic of yellow fever, may be 
seen by consulting Christison on Poisons. 

From a careful study of 200 cases, and the casual observation 
of twice as many more, I have found, that many had an interval 
of perfect health between the attacks, whereas others had only 
a remission, — that a number of both of these classes of patients 
had jaundice, hsemorrhages, and vomiting of black matters, — yet 
so distinct was the connecting link of cases between these groups, 
that it never occurred to me, (nor to any one else I suppose), to 
consider, that these variations in some of the phenomena, consti- 
tuted two distinct fevers. Symptomatic distinctions are import- 
-ant in the regulation of the treatment ; but, were they adopted in 
speaking of the pathology of the disease, would lead only to par- 
tial, and erroneous views. It is this arbitrary method of classifi- 
cation, and the dressed-up descriptions of systematic authors, 
which make it appear to the cursory student, that the fevers of 
tropical climates are difi'erent from those of this and other 
temperate countries, whereas were epidemics of different cli- 
mates studied as they actually occur, it would be found that 
fevers " differ as to their degree, but not as to their patho- 

logy.'" 

The various hsemorrhages in our yellow cases are apparently 
as common as in the yellow fever of the Mediterranean, and in 
various epidemics of the West Indies. Moreno, speaking of the 
Cadiz fever, remarks, that profuse menstruation was a common 
critical flux, and that it often occurred at the crisis in women in 
whom the catamenia had ceased a few days before ; he also states, 
that those seized with the fever when menstruating had a sudden 
stoppage of the discharge, with a recurrence of it to excess at 

1 As an illustration of the breaking up of an epidemic into different fevers, for the 
purpose of making a neat return, I subjoin one of the tables from the Army Reports 
referring to Jamaica, which is much more subject to yellow fever, and bilious remit- 



100 



PATHOLOGY OF THE DISEASE. 



the crisis. 1 Similar observations were also frequently made in 
my practice. 

5. The sliort duration of the pyrexial state^ and its mode of ter- 
mination. 

The general occurrence of the crisis so early as the fifth day, 
distinguishes this fever in a very marked manner from typhus. 
The termination in the former is also much more commonly in- 
dicated by sweating, or other critical evacuation. 

In the fever of 1817-20, Dr Welsh says, that "most frequent- 
ly no evacuation marked the crisis; but when any did make its 
appearance, it most generally took place by sweat, but, in a few 
instances, by diarrhoea, epistaxis, and great uterine hsemorrhage. 
Pustular eruptions, parotiditis, and carbuncle, were also occa- 
sional, though still rarer critical evolutions of the fever.'' All 
of these statements apply to the present epidemic, excepting 
the first, that most commonly the crisis is not marked by a 
critical evacuation. In almost, if not in all of my cases, it was 
otherwise, till within the last twenty days, W'hen certainly seve- 
ral cases have occurred, in which the patients have slowly, and 
without notable crisis, passed into convalescence. All of these 



tent, (wliicli is arbitrarily separated from it), than tbe islands included in what are 
termed the Windward and Leeward Commands. 





Admissions. 


Deaths. 


Proportion of 

Deaths 
to Admissions. 


Intermittent Fever, .... 
Remittent Fever, .... 
Common continued Fever, 
Yellow Fever (Icterodes) 

Total, 

Annual Ratio per 1000 of mean strength. 


6-090 
38-393 
1-971 
20 
448 


37 
5-114 

86 
15 
1 


1 in 165 
1 in 8 
1 in 23 
1 in 11 
1 in 448 


46-922 


5-253 


1 in 9 


910 


101-9 





The cases styled remittent fevers might very often, with as much propriety, have 
been called yellow fever; and m the other classes, difficulties would occur as to the 
distribution. 

1 Moreno. — Ensayo Medico-Practico sobre el Tifus Icterodes, fiebre amai-illa 
comunmente dicha, &c. Cadiz, 1813. " Za evacuacion mestrual en el hello sexd, apa- 
rece en los mas de los casos, .... aun en aquellas mugeres en quienes habia cesado 
pocos dias mites ; y en las que eran invadidas en iin tal estado, la evacuacion cesaha, vol- 
viendo a veces a presentarse pasados los mementos del espasmo perifericoJ' P. 44. 



PATHOLOGY OF THE DISEASE. 



101 



cases, however, were of the continued type, and gave no symp- 
toms of convalescence, earlier than the thirteenth, and some of 
them so late as the twenty-first day. 

A copy of the Medical Gazette for the 24th November has just 
been received, in which I find a very valuable paper, by Dr Mac- 
kenzie, on the fever now prevailing in that city, which is quite 
the same as our own.^ The following extract, which it contains 
from Dr O'Brien's description of the Dublin epidemic of 1826, 
may be here appropriately introduced, as it describes a fever very 
similar to that which forms the subject of this essay: — 

*' The other species of fever, or that of the new constitution, 
which constituted the bulk of this epidemic, was one of short pe- 
riods, terminating in three, five, seven, or nine days, but the 

second of those periods was the most frequent." "In 

this fever the chain of morbid actions was rapidly formed and 
rapidly terminated, and the disease developed itself with energy 
from the commencement. The access was sudden, and usually 
came on at mid-day. The person, previously in perfect health, 
would then be seized with sickness at stomach, headach, pain 
In the small of the back, and chilliness. On the approach of even- 
ing all these symptoms increased, and the febrile paroxysm was 
fully formed ; the chilliness increased to a rigor, and the nausea 
to vomiting, which harassed the patient for the first three or 
four days of his fever in the form of an empty straining, and fre- 
quently continued through its whole course. On the evening of 
the fifth or seventh days, the eooacerhatio critica commenced, 
which, mostly with the intervention of a rigor, but very frequently 
without this symptom, terminated in a profuse perspiration, which 
continued through the night, so that on the following morning 
the crisis was complete, and we generally found the patient con- 
valescent. We frequently received the glad tidings from him- 
self in the following words: 'Sir, I got the cool last night.' The 
cool^ however was sufficiently visible in his countenance, before he 
opened his lips; but unfortunately, in many instances, it proved 
only a delusive truce to his sufferings. The patient was destined, 
perhaps, to be harassed by one, two, or three relapses, which 
prolonged the whole duration of his illness even beyond that of 

^ Dr Mackenzie's paper is valuable, though all the statements which he makes are 
not correct. 



102 



PATHOLOGY OF THE DISEASE. 



the most protracted typhus. In fact, the liability to frequent re- 
lapses ^yas one of the most striking characteristics by which this 
fever was distinguished from all previous epidemics, at least 
which happened in our time. 

"Relapses, generally speaking, were milder and shorter than 
the original fever ; but to this many exceptions occurred. The 
general symptoms of the summer variety of this fever, in addition 
to those already mentioned, were — acute headach ; delirium, al- 
ways active, sometimes phrenitic ; rapid, and hard pulse ; white 
tongue, with florid edges, but sometimes natural ; muscular and 
arthritic, rather than deep-seated pains, or, as they are termed, 
' pains of the bones,' not accompanied, however, by swelling of 
the joints, except in a few instances ; the skin in many cases of 
a light yellow tinge, and sometimes, though rarely, assuming the 
intense icteroid yellow, characteristic of jaundice, and true yel- 
low fever."''^ 

6. Severe muscular and articular pains in the disease^ and during 
convalescence. 

This is, in several points of view, a very interesting pecuharity 
of the present fever. The patients have acute rheumatic attacks, 
and occasionally acute pain in the feet, just like those which were 
affected with the epidemic of 181 7-20, as we learn from Dr Welsh. 
" A very common symptom, occurring sometimes in the disease, 
but oftener during convalescence, was rheumatic pain of the joints, 
which occasioned considerable annoyance to the patient, and was 
removed with difficulty. Severe pain of the feet, with shght 
oedema, was likewise observed in a few cases in the stage of con- 
valescence." P. 18. 

1 " In Rutty's History of the Diseases of Dublin during forty years, we meet with 
several instances of an epidemic, of the same character with that now under consi- 
deration. Thus in July, August, September, and October, 1739, a fever prevailed, 
which was "attended with an intense pain in the head. It terminated," says he, 
"sometimes in four, for the most part in five or six days, sometunes in nine, and 
commonly in a critical sweat : it was far from being mortal. I was assured of seventy 
of the poorer sort at the same time in this fever, abandoned to the use of whey and 
God's good providence, who all recovered. The crisis, however, was very imper- 
fect, for they were subject to relapses, even sometimes to the third time." (p. 75.) 
He describes the same remittent fever as occurring also in 1740, 1745, 1764, and 
1765 ; noticing as a circumstance of the disease in 1765, that the bowels were in 
some instances remarkably affected." — Mackenzie in Medical Gazette. 



PATHOLOGY OF THE DISEASE. 



108 



I have found the arthritic and general pains in the jaundiced 
cases, to be most severe; — an observation worth recording, from 
the connexion which subsists between jaundice and rheumatism, 
as has been particularly adverted to by Dr Graves/ 

I find articular pains, mentioned by Don Francisco Flores 
Moreno, as having occurred in the yellow fever which prevailed 
at Cadiz, in 1800, 1804, 1810, and 1813. This acute observer 
remarks : " Another symptom not mentioned by any author, and 
which has often been noticed on the 6th day, as indicative of a 
favourable termination, consists in acute pains in the various 
articulations, particularly in the wrists, preventing all motion 
on the part of the patient. They have never continued after the 
night of the 7th day, when this affection has terminated in a re- 
storation to health, or in a true ataxy ending favourably.''^ In 
the present Edinburgh epidemic, the muscular and articular pains 
are also most severe in the commencement of convalescence. 

7. The rosy elliptical eruption resembling measles is absent in 
almost emry case in the present epidemic. 

Certainly, one of the most remarkable distinctions between the 
symptoms of the epidemic which now prevails, and that which 
has been common in Edinburgh for a number of years past, is 
the absence, with some rare exceptions, of the rosy, elliptical, 
and elevated spots resembling measles, which disappear on pres- 
sure, and return when the pressure is removed. At the time 
when Dr Alison published his short account of the present epi- 
demic, he had not met with any cases of the new, or " short 
fever,"" as he terms it, in which measly eruption was seen, a cir- 
cumstance not at all remarkable, considering the early date of 
his paper, and the extreme rarity of this occurrence.^ The early 

' Clinical Medicine, p. 564. 

^ Moreno. — Ensayo Medico-Pi-actico, sobre el Tifus Icterodes, fiebre aniarilla, 
comunmente dicha, &c. Cadiz, 1813. The following is the passage quoted in the 
text: " Otra send ha soli Jo presentarse en el dia 6° de la eiifermedad, {de la que no 
haya hecho mencion algun autor), y la qual anunda la favorable tervnnacion de ella. 
Consiste esta, en unos vivos dolores de varias articidationes y jmncipalmcnte de las vmne- 
cas, que impiden todo movimiento al pacienie, mas mmca han pnsado de la voche del dia 
7° en al que con tal sintoma ha ierminado siempre la enfermedad en salad, 6 en una vcrda- 
dera ataxia cuyo exilo ha sido favorable." P. 60. 

3 The passage in Dr Alison's paper, to which reference is made in the text, is as 



104 



PATHOLOGY OF THE DISEASE. 



date of Dr Craigie's paper also accounts for his making an even 
stronger statement on this subject, viz., — " no eruption of spots 
is observed similar to that observed in genuine typhus."^ 

To give a correct idea of the striking nature of this difference 
between the two fevers, I may quote what Professor Henderson 
says in the report made conjointly by himself and Professor Eeid 
regarding the epidemic fever in Edinburgh. He says, that 
"130 cases of both sexes were specially inspected with reference 
to this eruption. In 108 cases, the eruption was found; in 22, 
it was not found. Six of the 22 were not admitted till between 
twelve days and three weeks from the beginning of the fever ; 
therefore, as will appear from what follows, it cannot be con- 
cluded that they had not had the eruption at an early period. 
Of the 16 cases in which no eruption existed at any time, the 
greater number were slight cases; one only could be termed a 
rather severe case, extending to the 15th day.^ Dr Craigie ob- 
served the typhoid eruption only in 79 out of 169 cases.^ 

Many observers have reported upon the presence of the erup- 
tion in the contemporaneous G-lasgov/ fever of that period, and it 
appears, that it has there been very carefully looked for, and very 
generally observed. Dr Cowan, in 1835-36, found, that in 2000 
cases, 7SyVo P^^ cent, admitted had the eruption. Dr Perry, 
another Glasgow physician, considers contagious typhus to be an 
exanthematous disease, like small-pox, measles, and scarlet 
fever. 

We find a similar opinion entertained by most modern physi- 
cians, either in a limited or unlimited way. Dr Alison, writing, 
in 1827, of the Edinburgh fever, says that the measly eruption 
is a symptom occurring in the majority of cases, and that the 
fever characterised by it is a connecting link between continued 
fever and the contagious exanthemata. This opinion is probably 
correct. It is not, however, my object here, to adduce argu- 
ments for or against any particular view of the pathology of 

follows : — " None of those cases I'unning this short course have shown the true fe- 
brile eruption, resembling measles, although many have shown petechiee, or circum- 
scribed purple spots, originating in flea-bites, and extending apparently by little 
ecchymoses." — Scottish and North of Enyland Med. Gazette, No. i. p. 1. 

1 Edin. Med. and Surg. Journal, Oct. 1843, p. 411. 

2 Ibid. No. 161, for Oct. 183,0, p. 437. 

3 Ibid. Vol. xxvii. p. 301. 



PATHOLOGY OP THE DISEASE. 



105 



typhus fever, but siraply to show, that the absence of measly 
eruption in the present epidemic does indeed distinguish it, 
so far as this character is to be regarded as diagnostic, from 
typhus, which is the most common form of continued fever in 
Edinburgh, and other places. And further, that its general ab- 
sence, and occasional presence, are both points of resemblance 
between it and the epidemic of 1817-20, described by Dr Welsh, 
and which, in all its leading features, is identical with the present. 
That gentleman says, that " a measly-looking efflorescence on the 
iskin was occasionally observed" in that epidemic. 

While the almost universal absence of the typhoid eruption 
presents an obvious difference between the phenomena of the ordi- 
nary and present epidemics, yet, its occasional presence suggests 
to us the important inquiry, whether the two fevers, though appa- 
rently so different, are not the results of modifications of the same 
morbid poison l 

On this subject Dr Alison remarks : " It is a curious and inte- 
resting question, whether this kind of fever has proceeded from 
the same poison as the usual typhoid fever of Edinburgh, or is 
truly a separate disease ? It is quite certain, that the one has 
succeeded the other, within narrow limits, both of time and space, 
in different parts of the town; and I have seen two instances, in 
which strictly typhoid cases, with the characteristic eruption, 
have been brought in from the same rooms, in which a succession 
of the milder cases have occurred at the same time. But, on the 
other hand, I am aware of several cases, carefully investigated 
by my friend and colleague, Dr Henderson, in which a succession 
of protracted typhoid cases has been traced to one room, while 
all the cases in the neighbourhood have been of the mild and 
short fever. And one man under my care, after passing through 
a protracted typhus, with the characteristic eruption, and threat- 
ening of ulceration of the bowels, relapsed, with the symptoms of 
the usual epidemic, of which cases were lying beside him, and had 
the usual crisis, and second relapse, — so that he might be said 
to have gone through both diseases in their present form, before 
leaving the ward."^ 

We find the ordinary eruptive typhus driven from the field; 

' Alison. — Scottish and North of England Medical Gazette, No. i. p. 3. 

P 



106 



PATHOLOGY OF THE DISEASE. 



— the present form of fever gradually springing up as the other 
decreased. I am aware, that it has been alleged, in conver- 
sation, by some physicians, that the few cases which have pre- 
sented the rose-red fever eruption did not relapse, — were of the 
continued type, — and, in fact, were cases of a different disease. To 
this opinion, I was also at first strongly inclined, more especi- 
ally, as it was currently alleged, that these cases could be traced 
to foci of contagion, where the same form of the disease pre- 
vailed. This opinion, however, is not tenable. It may be true 
that the cases of what are termed " true typhus," come pretty 
generally from the same houses; but then, do they not come also 
from the same families? May it not be peculiarity of constitution 
in these individuals, which determines this particular manifesta- 
tion of the morbid poison ? Though the constitution of an epi- 
demic gives to it a character, yet idiosyncrasy causes families 
and individuals to be affected differently from the generality of 
persons. Who will maintain that the scarlatina poison does not 
produce mild cases, without sore throat and eruption, as well as 
those with one or both of these characters? 

Now, no person who saw the rosy spots in the case of Mary 
Wallace, on their first eruption^ could say, that it was not the true 
measly typhus eruption ; and yet, the bronzing, purpling, and 
jaundice, along with the urgent vomiting, rheumatic pains, and 
the relapse at the usual period, proclaimed unequivocally, that 
she was afflicted with the prevailing epidemic ; or rather, per- 
haps, a sort of bastard between the two forms of fever. She 
took the fever in the hospital, where, at the time of her seizure, 
there was not a single case that either had, or had had typhus 
eruption. Facts are wanting, to enable us to speculate with ad- 
vantage upon the question, as to whether all of those occasional 
cases with eruption proceed from the same poison as those with- 
out it ; but this, at all events, can be stated, that there is such a 
thing as pe^^sons being occasionally affected with the measly eruption^ 
in addition to the usual symptoms of the present fever ; such per- 
sons, moreover, apparently getting the disease from a contagious 
poison evolved from, or generated by persons congregated to- 
gether, affected only with the prevailing form of the fever. 

When I commenced the observation and study of the present 
fever, and indeed for a considerable time afterward, I regarded it 



PATHOLOGY OF THE DISEASE. 



107 



as essentially^ and totally^ different from typhus ; but recent cir- 
cumstances, and more matured weighing of evidence, have greatly 
modified this opinion. In the case of Mary Wallace, a bastard 
fever was distinctly recognised; and as the season advanced, all 
the cases have been more characterized by depression and gene- 
ral typhoid symptoms. The cases of continued fever, with and 
without measly eruption, are becoming more common in Edin- 
burgh, and also in Glasgow, as Dr Weir of the Hospital there 
informs me. 

If some think, that on this point there has been exhibited an 
undue reluctance to enter fully upon an important pathological 
inquiry, I beg to remind them that data are yet wanting to entitle 
us to discuss it fairly, and with profit. This may be attempted 
in a subsequent publication, at the close of the epidemic; in the 
mean time let the remark of Rousseau be remembered, "that the 
truth is in the facts, and not in the mind which observes them ;" 
and it is hoped, that some important facts have been even here 
communicated as contributions to this part of the pathology of 
the fever.^ 

8. Severe vomiting is much more common^ as are likewise gastric^ 
gastro-liepatic^ gastro-splenic, and gastro- enteric symptoms. 

Even in the mild cases, more or less pain of the epigastrium 
and vomiting are general symptoms. They have been urgent in 
the majority of those whom I have treated, both in the New 
Fever Hospital, and subsequently in the Infirmary. They have 
not always gone together ; and even in some fatal cases, in which 
the black vomit occurred, there was no pain or tenderness of the 
epigastrium. 

In the mild cases, the matters vomited are generally the in- 
gesta tinged with green, of various degrees of intensity. If the 
patient drinks incessantly, which is usual, the deepness of the 
green is less intense, from the immense quantity of fluid which is 
constantly being taken into, and at once ejected from the sto- 
mach, diluting the colouring matter ; for it is very common for 
every thing, as soon as swallowed, to be discharged. 

' An eruption like scarlatina, as well as other eruptions, has been observed hy 
Dr Rush, in yellow fever. 



108 



PATHOLOGY OF THE DISEASE. 



In the most malignant of the yellow cases, there is sometimes 
a fine inky sediment in the vomit; at other times, the grounds 
are grumous, — in consistence, like the thick part of hare soup, 
and varying in colour from dark-brown to black. In a fatal 
case which occurred to me the other day, there was a thick 
matter at the bottom of the vessel, resembling the dark-green 
mud which collects in pools of stagn^g^ water. Upon repeated- 
ly washing this sediment with water, the green colour was al- 
most removed, and what remained was like the grounds of hare 
soup. 

The grumous matter of the black vomit, in its various forms, 
is unquestionably blood extravasated from the capillaries of the 
stomach, and chemically altered by the action of the acids of the 
stomach upon it. That the black vomit is altered blood, has been 
again and again demonstrated at our autopsies, by tracing it to 
the sources of its extravasation, and finding large clots of blood in 
the submucous cellular tissue of other parts of the intestines in 
the same cases. The black colour is probably produced by che- 
mical action between the acids of the stomach, and the iron of 
the blood. 

The reader will be the better able to judge of the correctness 
of these remarks on the source of the black vomit in the present 
fever, by perusing the reports of cases already detailed, but par- 
ticularly of some which I have had in the Royal Infirmary, to 
^dde(J in the Appendix.^ 

' The following note by Dr Gillkrest on the black vomit is interesting: "Dr Bone, 
who seems to have paid much attention to the examination of the fluids ejected from 
the stomachs of persons labouring under yellow fever, describes them thus: * 1st. 
The contents of the stomach at the invasion of the disease. 2d. The fluid drunk, 
mixed with green or yellow bile. 3d. The fluids drunk, without any admixture or 
change. 4th. A fluid like indigo or China ink, bi'ought up with some straining: I 
suppose it to be bile, for it coagulates with spirits of wine. 5th. A brown fluid, re- 
sembling urine in appearance. 6th. Brownish blood, not flaky, proceeding from the 
fauces and gums, and perhaps partly, in some cases, from the pulpy cardiac opening 
of the stomach. 7th. Brown flaky blood, mixed with mucous matter, proceeding 
from the gums, fauces, and stomach, usually the precursor of the real black vomit. 
8th. The real black vomit, which also is blood altered by its passage through the ves- 
sels of the villous coat.' At Gibraltar, in 1828, we were led to consider 'black vomit* 
under the following forms: 1st. In thin flakes or portions of a brownish black colour, 
floating, like broken-up wings of a butterfly, in a glairy fluid, or in a fluid resembling 
an infusion of black tea. 2d. A perfect resemblance to a mixture of soot and water, 
or to the contents of a coff'ee-pot when the clear part of the coffee has been poured off". 



PATHOLOGY OF THE DISEASE. 



109 



What is said by Blane, of the affection of the stomach and 
vomiting in the yellow fever of tropical climates, applies to our 
present yellow cases. " In all stages," says he, " of this disease, 
it is the affection of the stomach that affords the most distin- 
guishing and important symptoms. As it advances, an uncon- 
querable irritability of this organ comes on. Whatever is swal- 
lowed, whether solid or fluid, of whatever quantity or quality, is 
immediately rejected by vomiting. An almost incessant retching 
takes place, even without any extraneous irritation, which com- 
monly on the third day ends in what is called the hlack vomit^ the 
most hopeless of all the symptoms attending it."^ 

The acute pain which many patients complain of, when press- 
ure is made over the stomach and duodenum, seems, in the majo- 
rity of cases, to depend on flatulence alone. At all events, when 
accompanied by gaseous distension, which it generally is, I have 
found far more advantage derived from turpentine enemata, car- 
minatives, and fomentations, than from leeches. 

Fulness of the liver has been noticed during life, in several 
cases : but not so frequently, as the same affection of the spleen. 

Congestion of the spleen has occurred in a considerable number 
of cases. From the great enlargement of the organ, and the 
pain which the slightest pressure over it excited, I at fir^t 
treated the affection as acute splenitis, but more careful consider- 
ation has now induced me to regard it simply as a congestive 
affection; especially from the enlarged spleens which I have had 
an opportunity of examining after the death of the patients, pre- 
senting congestion only. The enormous congestion of this organ 
has as little to do with inflammation, as any of the other conges- 
tions met with in the fever. 

As a good example of this complication of the fever, the fatal 
case of Daniel Lamb (to be given in the Appendix) is referred to. 

3d. A homogeneous, intensely black substance, having a jelly-like consistence, and ad- 
hering in great abundance sometimes to the mucous coat: this, though never vomited 
up, and therefore more properly belonging to the morbid appearances, it is thought 
may not be altogether out of place here:— it is rarely found in the stomach, the in- 
testines being much more commonly its seat. A simple test of true black vomit has been 
proposed, which is dipping into it white paper, which it does not im^G:'-Op. cit. p. 274. 
^ Blane. — Diseases of Seamen. London, 1799, p. 410. 



110 



PATHOLOGY OF THE DISEASE. 



The subjoined case will point out what the splenic symptoms 
commonly were, in those who recovered from congested spleens. 
At the time of its occurrence, it was believed to be inflammatory. 

Case XXV. — Summary. — Coma on the ^th day. — Relapse on 
the 14}th day — enlarged and tender spleen on the \%th day — sweat- 
ing and sudamina on the 19 th. Treatment ; leeches^ tartar emetic, 
S^c. Recovery. 

James Pugh, a native of Edinburgh, aged 15, from Hamilton's 
Close, Grassmarket, was 

Admitted., 1th August, {sixth day.) His mother states, that he is 
an apprentice to a tobacco manufacturer, but that he has been out 
of employment for the last six months, and during that time 
his food has been scanty. He had fever six years ago, and w^as 
treated in the Glasgow Infirmary, No one is aware of his having 
been exposed to contagion. 

He took ill on the 2d August with rigors, headach, pain of 
the back, and loss of appetite ; and since then, languor and rest- 
lessness have been superadded. There is no fever eruption. 

9th August, (eighth day.) Since he came into the Hospital, he 
has had purgatives, and a little wine. On admission, he was 
speechless; and he can now only with difficulty be roused to answer 
questions. The bowels are slow : he complains of acute pain 
in the precordial region, and pressure on this part augments it. — 
Applicentur hirud. iv parti dolenti. — Haheat vini rubri ^iv. — 
8umat statim olei ricini tj- 

Vespere. — He is much more lively, and the countenance is al- 
most natural, as are also the tongue, skin, and pulse. 

IBth August, (fourteenth day.) Relapsed. The wine was 
omitted on the 1 1th. Since last report, he has been gradually 
improving in every respect till to-day, when he has had a good 
deal of feverishness, and headach, but no rigors. 

18th August, (seventeenth day.) On the evening of the 16th, 
and last night, he had sweating without any rigors. He has 
a good deal of abdominal tenderness; no enlargement of the 
liver or spleen can be detected. The bowels are regular ; the 
pulse is 100, of good strength ; the urine copious, and the appe- 
tite good. — Admoveantur hirudines iv parti dolenti. — Haheat, 
hord somni, pulveris Jacobi veri gr.v. 



PATHOLOGY OF THE DISEASE. 



Ill 



19th August, {eighteenth day.) Yesterday, between 3 and 4, 
P.M., he had a good deal of sweating, but he has had none since 
then. The leeches bled well, and have removed the pain from 
the part to which they were applied. The spleen can be dis- 
tinctly felt to be enlarged, and to extend downwards an inch 
and a half below the ribs ; there is pain, on pressing over it. 
The diaphragm descends less freely than naturally. The coun- 
tenance is flushed ; the respirations are 24 ; the pulse is 120, and 
sharp ; the skin is hot, and dry ; the tongue is clean, but dry ; 
there is much thirst ; the bowels are regular. He slept well last 
night. — B. calomelanos gr.iv, puheris antimonialis gr.v, Misce. 
Hdbeat hord somni. — Habeat sulphatis magnesice Ziij, ex aqud^ eras 
mane. — To have a hottle of ginger leer. 

20th August, {nineteenth day.) He slept well last night. The 
powder was administered at 10 p.m. He began to sweat at 6 a.m., 
and still continues perspiring profusely. On the abdomen, suda- 
mina are distinctly perceptible. There is no pain in the region of 
the spleen, and much less turgidity of the organ. The pulse is 
80, and feeble ; the tongue clean and moist ; he has great thirst, 
slight headach, and much debility. — Quiescat. 

2lst August, {twentieth day). The sudamina, observed yester- 
day, are equally visible to the eye, but not so perceptible to the 
touch. He has had no more sweating. He complains of general 
headach, and intolerance of light. The lachrymal secretion is de- 
ficient, and the pupils are much dilated. There is general abdo- 
minal tenderness, especially in the region of the spleen. The 
bowels have been opened twice. He has taken no medicine since 
the 19th. — B. aquce acetatis ammonioe ^m, tartratis antimonii 
et potassw gr.i, syrupi simplicis %i. — Misce. Sumat §^ ex aqud^ 
Stid q. q. hord. 

22d August, {twenty-first day.) He slept well last night, and 
feels more comfortable to-day. The headach is less ; the bowels 
are open. He had some sweating during the night, and the skin 
is at present moist. — Continuatur mistura. 

24<th August, {twenty-third day.) Has been doing well since 
the 22d, and has now neither headach nor abdominal tender- 
ness. The skin, tongue, and expression are natural. The appe- 
tite is improved. The pulse is 80, and deficient in strength. — 
To have common diet. 

Wth September, {forty-first day.) Since last report, he has 



112 



PATHOLOGY OF THE DISEASE. 



been steadily improving, and since the 29 tb, has had full diet. 
He is now dismissed, quite well, and not complaining of feebleness. 

G astro- enter iG symptoms are, in general, obviously referable to 
the congested and irritated state of the mucous membrane of the 
stomach and bowels. There seems good reason, also, to believe, 
that in many cases they are aggravated by loose clots of effused 
blood, and the vitiated secretions themselves, which acting as fo- 
reign bodies, tend still farther to increase the irritation. This 
accounts, probably, for the protracted diarrhoea in some severe 
cases which recovered. Much of the pain, however, which is com- 
plained of in the bowels arises from gaseous distension : we see 
it occurring, in some of the mildest cases, to a great extent. 

A few other of the most important points in the pathology of 
the disease must be noticed. Those to which it is proposed t© 
advert, are, 

\st^ The state of the blood; 

2c?, The origin and mode of propagation. 

3c?, The structural lesions caused by the fever; 

1 . The state of the hlood. 

There seems good reason to believe, that a number of indivi- 
duals, who do not actually succumb under the influence of the 
epidemic, are nevertheless affected by it in a marked and charac- 
teristic manner, such as by slight chills and sweatings, some head- 
ach and vomiting, with prostration of strength. All of these 
symptoms, in a mild form, may occur combined, or some of them 
only may be present. In one instance, in which the whole of the 
group of symptoms occurred, along with bronzing of the counte- 
nance, they entirely disappeared within twenty-four hours, an 
emetic having been given three hours after their invasion. The 
patient, referred to, is the nurse Margaret M'Kenzie, who, at a 
subsequent period, went through a well-formed ordinary attack of 
the disorder. The other occurred in my own person; the symp- 
toms entirely disappeared, after a two days' absence from Edin. 
burgh, in the Highlands of Argyleshire. It would be easy to 
multiply illustrations of this description; but it is not necessary, 
as most persons are willing to admit, that ephemeral and ill- 
formed cases are by no means uncommon during the prevalence 



PATHOLOGY OF THE DISEASE. 



113 



of every epidemic. Probably, change of air, either alone or 
conjoined with the use of certain remedies, such as Labaracque's 
chlorinated solution of soda, might, in a considerable number 
of cases, have proved sufficient to ward off, or, perhaps more 
correctly speaking, to arrest the disease in limine. This belief 
is principally grounded upon the fact, that for some days be- 
fore there exists any other evidence of the presence of the 
disease, the countenance assumes a peculiar premonitory hue, 
indicating, I apprehend, a dissolved state of the blood, and a want 
of tone in the capillary vessels. When the vital fluid is still 
more dissolved, in the subsequent stages of the disorder, we also 
find an increased ability to circulate in the capillaries, from the 
enlarged calibre or relaxed state of these vessels, — disabling the 
organs of secretion from performing their functions from conges- 
tion; as is frequently manifested by the scanty urine and yellow 
skin, which latter symptom, as the cases detailed sufficiently prove, 
does not arise from any obstruction in the biliary ducts, but de- 
pends upon the bile not being separated from, or being reabsorbed 
by the blood. Another class of symptoms, produced by this ca- 
pillary congestion, is hsemorrhage from the mucous membranes, 
with occasional black vomit.^ 

That the blood really is in a dissolved state, was made perfectly 
manifest to us, first, by the imperfect coagulation which it under- 
went when drawn from the veins of patients, a homogeneous 
spongy mass being formed, in place of a firm fibrinous clot, with 
a supernatant serosity; second, by the ecchymosis which was uni- 
formly observed to surround flea-bites or other slight injuries of 
the skin; third, the frequent occurrence of purpurous spots; 
fourth, the hsemorrhages ; and, fifth, the discoveries made by the 
microscope. 

Professor Allen Thomson had the goodness to lend me his able 
assistance, in examining the blood of a number of my patients, by 
means of the microscope. A few drops were taken from the thumbs 
on the same day (24th Oct.), of about a dozen persons, some of 
them in the pyrexial, and others in the apyrexial stage of the 
disorder; and it was found, that in all of them, there were an 

• For some valuable i*emarks on the state of the capillaries in fever, see Dr Craigie's 
learned work, on the Practice of Medicine. 

Q 



114 



PATHOLOGY OF THE DISEASE. 



unusual number of pus globules; and in some cases, in addition 
to this, all the globules were found serrated and notched. One 
gentleman present upon this occasion, was observed to have his 
blood exactly in the same state as the fever patients, and within 
two days he was seized, and went through two mild attacks, or 
to use conversational phraseology, — the fever and tJie relapse. The 
blood of some other healthy persons was also examined at the 
same time ; it exhibited nothing unnatural, and none of these lat- 
ter individuals have taken the fever, although more than a month 
has now elapsed since the observation was made. 

I have been told by Dr Douglas Maclagan, that he has detect- 
ed urea in the fluid found within the ventricles of the brain, and 
in the blood of one or two of Dr Henderson's fever patients, in 
whom he looked for it, at that gentleman's request. The obser- 
vation is one of great interest, but not different from what might 
have been anticipated. Since an early period of the epidemic, I 
have treated a certain class of head symptoms by cupping in the 
lumbar region, and diuretics, from a belief that urea was circu- 
lating with the blood, in consequence of the kidneys being incap- 
able, from congestion, of exercising their function. I apprehend, 
however, that urea is seldom abundant in the blood of our fever 
patients, as it is extremely rare to meet with symptoms at all 
resembling those known to characterize the peculiarity of its 
action as a poison, especially resembling foxglove in its effects; 
and according to the concurrent testimony of many, such are the 
toxicological manifestations of urea, when administered to ani- 
mals as a poison, or to the human subject as a medicine.^ The 
muscular and articular pains may possibly depend on urea. 

Dr Stevens has particularly described the morbid character 
of the blood in yellow fever. In the days of exclusive humoral 
pathology, it was pointed out by many, that the blood was in a 
dissolved state in this and other fevers; but it is only recently, 
that attention has been recalled to the fact. Dr Mitchell men- 
tions, that, in the yellow fever of Virginia in 1741, "blood drawn 
from a vein was invariably dissolved ; the same state of the blood 

^ Urea is composed of oxygen, 26.54 ; hydi'ogen, 6.71 ; carbon, 20.02; azote, 46.73. 
It has been used in diabetes ; when we recollect its highly azotised constitution, it is 
not wonderful that it proved useful. Some suppose urea to be diuretic in doses of 
gr.xv. to 9i, but there is no good ground for this belief. 



PATHOLOGY OF THE DISEASE. 



115 



was always observed in many persons who had been exposed to 
the miasmata who discovered no other symptoms of the dis- 
ease." On the fourth day after the attack, Dr Mitchell uniformly 
took a few ounces of blood from the temporal artery, when he con- 
stantly found it dark and venous-looking. Dr Potter of Balti- 
more, Dr Copland, and others, have recorded many similar expe- 
riments. 

2. The origin and mode of propagation. 

That the prevailing is strikingly different in its phenomena from 
the ordinary fever of Edinburgh has been already fully established; 
although, purposely, no dogmatical opinion has been expressed, as 
to whether the morbid poison which causes the present disease 
be or be not that which gives rise to the true exanthematous 
typhus, merely modified by the operation of other poisons, ter- 
restrial, atmospheric, or imported. 

Regarding the progress of the prevailing disease in this coun- 
try, since its first appearance, at least twelve months ago, in 
Dundee, Greenock, and elsewhere, I have collected some interest- 
ing data, which, should I have leisure and ability to add to, may 
serve to throw some light on the history of its progress. In the 
mean time, it may be intimated, that facts are not wanting to 
give colour to the belief, that the disease has been imported into 
this country : but certainly, I have heard of none which do more 
than this. 

The disease is contagious. Of this we have sufficient evidence 
in the fact, that almost all the clerks, and others exposed to the 
contagion, have been seized. Dr Heude, and his successor Mr 
Reid, in the New Fever Hospital; Dr Bennett, my successor there; 
Mr Cameron, and his successor Mr Balfour in the adjoining 
Fever House; as well as most of the resident and clinical clerks 
in the Royal Infirmary, have gone through severe attacks during 
the past summer and autumn. Hardly any of the nurses, laun- 
dry-women, or others coming in contact either with the patients 
or their clothes, have escaped; at one time, there were eighteen 
nurses off" duty from the fever; and of those who have recently 
been engaged for the first time, or of those who have hitherto 
escaped, one and another is from time to time being laid up. 



116 



rATIlOLOGY OF THE DISEASE. 



It may be fairly objected, that while these illustrations incon- 
testibly prove that the disease is contagious, they do not give a 
fair view of the degree in which it is so, inasmuch as all the indivi- 
duals specified were not only much exposed to the poison, but were 
also, from the laborious nature of their respective duties, pecu- 
liarly predisposed to succumb under its influence. It is admitted, 
that fatigue is a predisposing cause; and also, that the contagion 
is rendered infinitely more dangerous by the consortus cegrotorum^ 
even in well-ventilated fever wards, than it is in other circum- 
stances. 

Long-continued exposure to the poison seems also to operate 
most evidently against the chance of escape, as we find that com- 
paratively few of the Dispensary medical officers and pupils — a 
very numerous class — have taken the disease. These gentlemen 
are much exposed to the fever, and undergo a great amount of 
fatigue ; but they are generally with their patients only for short 
periods, and have constant opportunities of inhaling an unconta- 
minated atmosphere. 

I have seen and heard of a considerable number of isolated 
cases, of various degrees of severity, in the best districts of the 
New Town; but have never yet known of an instance of the 
disease propagating itself in these localities. The same obser- 
vation has been made by several medical friends, at whom I 
have made inquiries on this subject. That at a more advanced 
period of the epidemic, it may gain a footing in the New Town, 
would not be at all remarkable, considering the unrestricted in- 
tercourse between the poor of the infected, and the wealthy of 
the uninfected districts. Besides, the midnight labours of the 
gay season will soon be in operation as a predisposing cause. 

Those London physicians who have had the best opportunities of 
observing typhus fever, believe, that the poison in which it origi- 
nates, does not extend for more than three or four feet from the 
patient; or, at all events, that at a greater distance, it becomes 
so diluted by the atmosphere, as to be innocuous.^ 

* Believing in the certainty of this law, the fever patients are distributed (with im- 
punity, it is said,) throughout the general wards of most of the metropolitan hospitals, 
care being taken, that they are placed at due distances from each other, and from the 
rest of the patients. If these fever patients are too numerous in the ward, the atmo- 
sphere becomes tainted with the morbid poison, and the disease spreads. Similar re- 



PATHOLOGY OF THE DISEASE. 



117 



It appears, that the contagion of the fever at present prevail- 
ing is subject to a similar law. James Middleton was sent to 
ray fever ward, No. 6, in the Royal Infirmary, by the admitting 
clerk. When I first saw the patient, on the following day, I found 
that he laboured under empyema and disease of the heart, but 
neither had, nor had had any symptoms of the fever* I imme- 
diately ordered his removal to a general ward, but unfortunately 
my orders could not be, or at least were not executed, till the 
evening of the following day, when he was taken to No. 4, after 
having been in the fever ward for about fifty hours. During 
the first day of his residence in the general ward, he continued 
without any symptoms of fever ; but on the forenoon of the fol- 
lowing, he had the usual initiatory febrile paroxysm, in so well- 
marked a form, as to convince me from the first of its nature. 
On the 5th day from his seizure, he died, intensely yellow, having 
had much inveterate vomiting, and black vomit for some hours 
before his death. In the next bed to this man, lay Daniel 
Lamb, an epileptic patient, who was in the habit of sitting on 
the fever man's bed during a great part of the day. He was 
the only patient in the ward who had any intercourse with him, 
and he was the only one who was seized with the fever. He 
took ill on the day that his neighbour died ; and within five 
days, he also died, with exactly the same symptoms. These two 
cases were the most rapidly fatal, and the most malignant in 
their symptoms, of any that I have seen; and yet, of the other 
sick and convalescent patients in the ward, (always above twenty 
in number,) none have been seized with fever since these deaths 
took place. 

From the number of laundry-women that have been attacked, 
it appears, that the clothes of our fever patients are especial re- 
positories and communicators of the morbid poison. An inte- 
resting fact, which may be introduced here, as it is probably to 
be explained by what has just been stated, was communicated to 
me by Mr Nicholson, from the Island of Skye, one of my pupils. 
He informed me, that two reapers, who had had the fever in 

suits have followed the same experiment in this Infirmary; and I am quite satified, 
that were the fever patients cautiouahj diffuf;e,d ihrough the general wards, the lives and 
health of many physicians, clerks, and nurses might be spared. 



118 



PATHOLOGY OF THE DISEASE. 



Edinburgh, arrived in his neighbourhood after their return 
home at the close of the harvest, when not a single case of 
the fever had been seen in the district. The mother of these 
persons, with whom they lived from the time of their arrival, 
was, in a few days, seized with the disease, and died. Other 
severe, and, in several instances, fatal cases occurred among the 
neighbours, who had waited upon her ; and the disease is now 
spreading to such an extent over the whole territory as greatly 
to alarm the inhabitants. The people consider it a new pestilence 
among them, and are so dismayed at its appearance, and so 
afraid of its contagion, that they are ceasing to attend at church 
on Sunday. It is not, of course, to be supposed, that all of the 
Skye cases have originated in the arrival of the two individuals 
referred to ; because shortly after they returned, many others 
came back from their annual visit to the south, among whom 
were not a few who had been patients in the fever hospitals of 
Edinburgh and Glasgow. 

3. The structural lesions caused ly the fewr. 

The following summaries of all my dissections will enable the 
reader to see at one view, what are the structural lesions caused 
by the fever: — 

DISSECTIONS OF THE FATAL CASES IN THE NEW FEVER HOSPITAL. 
Name, Age, and Duration of the Disease. Appearances on Dissection. 



James Law, aged 74. 
Died on the 10th day. 
Vide page 25. 



Bile-ducts pervious; gall-bladder con- 
tained inspissated bile ; liver natural ; 
gastro-intestinal mucous membrane here 
and there dax'k-coloured, with submu- 
cous exudation of blood ; black matter, 
similar to what was vomited, found in 



- stomach, &c. ; the spleen weighed six 
ounces, and was under the average 
bulk ; kidneys not congested ; mem- 
branes of the brain not congested ; large 
livid patches on the external surface of 
the body, but no yellowness of the sur- 
^ face or internal parts. 



George Johnstone, aged 20. 
Died on the 7 th day. 
Vide page 29. 



' Bile-ducts pervious ; gall-bladder con- 
tained inspissated bile ; gastro-intestinal 
mucous membrane dark coloured, with 
black patches, and submucous exuda- 



-{ tion of blood; heart very soft; kidneys 
yellow in all their textures; liver natu- 
ral; yelloAv serum in ventricles of brain; 
brain natural ; yellowness of all the 

I white tissues. 



PATHOLOGY OF THE DISEASE. 



119 



Name, Agej and Duration of the Disease. 



Archibald Campbell, aged 40. 
The day of the disease on which he died is 
not known. 
Vide page 33. 



Jane Merrilees, aged 39. 
Died on the 14th day. 
Vide page 37. 

Mrs Morris, aged 45. 
Died on the 24th day. 
Vide page 46. 



Appearances on Dissection. 

I' Bile-ducts pervious ; gall-bladder con- 
tained tenacious inspissated bile ; gastro- 
intestinal mucous membrane vascular, 
with submucous exudation of blood ; 
stomach over one-third of its surface 
was very black, from blood effused on 
the surface of, and under the mucous 

-{ membrane, and the same appearance 
was found in other parts of the intes- 
tines ; spleen weighed eight ounces, and 
was easily broken down ; the white tex- 
tures generally were yellow; heart heal- 
thy; under endo-cardium, especially in 
the left ventricle, there was consider- 

L able effusion of blood. 

r Bile-ducts pervious ; gall-bladder con- 
tained bile ; spleen greatly enlarged, 
-| very soft, and weighed one pound seven 
ounces ; heart natural ; every where 

I much congestion. 

Old disease of the lungs ; ulceration of 
the bowels; black patches of altered 
blood in the rectum. 



James Middleton, aged 50. 
Died on the 5th day. 
Vide Appendix. 



Daniel Lamb, aged 87. 
Died on the 5th day. 
Vide Appendix. 



plg^pcyiONS OF FATAL CASES IN DR CORMACK S WARDS OF THE ROYAL 

INFIRMARY. 

f Empyema, and other disease of thQ 
chest of old standing ; intense conges- 
tion of all the internal organs ; extra- 
vasation of blood under, and black ad- 
hesive jelly upon the mucous membrane 
of the stomach, and duodenum ; spleen 
enormously distended, and weighed 2 
pounds — it broke down under the fin- 
gers, like loosely coagulated blood ; yel- 
lowness of the external surface, and of 
all the internal white textures; bile- 
ducts pervious, and a moderate quan- 
tity of bile in the gall-bladder; liver en- 
larged, apparently from old disease. 

f Liver firm, dark-coloured, and tur- 
gid with blood ; weighed 4 pounds 8 
ounces ; spleen easily broken down ; 
weighed 1 pound 11 4 ounces; bile-ducts 
pervious ; gall-bladder moderately full 
of very black thick bile ; in the sto- 
mach, a considerable quantity of the 
black matter usually found in such 
cases ; in the sigmoid flexure of the co- 
lon, submucous exudation of blood; cra- 
nial bones unusually thick ; a large 
quantity of yellow fluid in the ventricles 
of the brain ; numerous spicule) in the 
cavity of the cranium ; heart weighed 
1 5 ounces ; yellowness of the surface, 
Land the white textures of the body. 



120 



PATHOLOGY OF THE DISEASE. 



Name, Age, and Duration of the Disease. 



Appearances on Dissection. 



Archibald Davidson, aged 20. 
Died on the 9th day. 
Vide Appendix. 



f Liver firm ; of a dirty pale yellow colour; 
spleen was firm and natural — it weighed 
five ounces ; gall-ducts pervious, and 
black bile in the gall-bladder; black tena- 
cious j elly adhering to mucous membrane 
of the stomach, and other parts of intes- 
tinal canal ; large clots of blood in the 
submucous cellular tissue of the sto- 
mach ; the clotted blood encircled the 
caput coecum in thick bands under the 
mucous membrane ; the body was yel- 
low externally, as was likewise every 
white tissue within the body ; penis and 
scrotum had a dark gangrenous appear- 
ance, and on the latter, there was a 

V small excoriated surface. 



The jpost-mo7iem appearances must of course vary somewhat 
with the duration and malignancy of the disease; and a greater 
diversity of lesions would undoubtedly have been presented to the 
reader, had more dissections been obtained. Enough, how^ever, 
has been seen, and is here recorded, to indicate at least the na- 
ture of the lesions to be expected in similar cases : — viz. 1. Abun- 
dance or even excess of bile, and a pervious state of the biliary 
ducts'; and, 2. More or less congestion of organs, with frequently, 
extravasation of blood in various situations. 



These appearances are either identical with, or analogous to, 
what the majority of observers have noticed and described, as 
being those which are found in persons dying of yellow fever. It 
may be interesting to refer to a few of them. 

SOME OF THE PRINCIPAL ANATOMICAL LESIONS FOUND IN THE ''yELLOW 

FEVER." 



Appearances of the surface of the Body. 
According to many authors, the yellow colour of the surface of 
the body becomes more decided after death. This sometimes 
changes for a black or dingy hue, which is particularly well 
marked in the penis and scrotum. There are often slight exco- 
riations on the scrotum, and M. Bally and others have seen the 
penis, what they term gangrenous at its extremity. Dark lines, 
and black patches are frequently seen in the axilla, and other 
parts of the body. 



PATHOLOGY OF THE DISEASE. 



121 



b. Cellular tissue. 
Desmoulins found that, upon cutting into the cellular tissue, 
blood exuded, and gas escaped with a hissing noise/ 

c. Muscular tissue. 
The muscular tissue is of a darker colour, and softer texture 
than natural. Gillkrest mentioned some dissections made dur- 
ing the last Gibraltar epidemic, in which " blood was infiltrated 
into the minuter fibres of muscles," which were black and very 
soft. He states, " that in one man this infiltration took place 
into the whole of the muscles of the right thigh, the abductors 
excepted; in another, into the gastrocnemii of the left leg, and 
flexors of the right arm. In a third case, precisely half of the 
diaphragm (right side) was found in this state, and the infiltration 
bound down by the foldings of the peritoneum, extended in a 
most singular manner in one continuous sheet from the dia- 
phragm, posteriorly, down the right side to the bottom of the 
pelvis, keeping with great precision a line corresponding to the 
axis of the vertebral column, and covering every organ or part 
of intestine, &c., which lay on that side. It is worthy of notice, 
that, in this last mentioned case, there was no black vomiting. 
In none of the cases, were ruptured vessels detected.^ 

d. Thorax. 

There is often a yellow serous effusion into the pericar- 
dium, occasionally mixed with black blood, (Bally, &c.) The 
heart is generally distended with fluid blood. Ecchymoses of 
the pleura have been described by Dalmas. During the epi- 
demic of Leghorn, Lacoste,^ Palloni,^ and others state, that they 
not only found bloody effusions, but even gangrene of the dia- 
phragm, pleura, and abdominal muscles; but most probably, 
they mistook for gangrene, the infiltration of blood observed by 
Gillkrest. 

e. Abdominal Viscera. 
Stomach. — The blood-vessels of the external surface of the 

' Desmoulins. — Considerations sur I'cJtat anatomique de la peau, et du tissue cellu- 
laire dans la fievre jaune. — {Journal Complimentaire, t. xii. p. 17.) 

^ Gillkrest. — Cyclop, of Practical Med., vol. ii. p. 277. London, 1833. 
3 Lacoste. Dissertation sur la fievre regnante k Livoune, &c. 
* Pallom. Asservazioni mediche. Leghorn, 1824. 

R 



122 



PATHOLOGY OF THE DISEASE. 



stomach are generally enlarged and tortuous, — the inner sur- 
face being stained with red and purple, or even black patches; 
which appearances have led some to suppose, that during the pro- 
gress of the fever, this organ had been the seat of inflammation 
and mortification. Hence, some authors have considered gastri- 
tis or gastro-enteritis to be the pathological condition of the dis- 
ease — a fallacy from which the most dangerous practical conse- 
quences in this as well as in other forms of fever have resulted, 
however ingeniously such theories have been defended by Brous- 
sais and his disciples. 

The dark-brown or black patches visible on the internal sur- 
face of the stomach, are entirely the effect produced by contact 
with the secretion called black vomit, as when this is thoroughly 
washed away, the mucous coat becomes pale, or merely a slight 
stain is left. Sometimes, instead of patches, the whole mucous 
membrane presents one uniform brown tinge ; in other cases, it 
is quite pale. It is generally loose, and easily abraded. When 
torn ofi^, it often appears like a congeries of engorged capillaries ; 
numerous red spots are seen immediately beneath it, particular- 
ly at the cardiac extremity, presenting the appearance termed 
by the French rongeur pointillac. Duflot^ and others have de- 
tected a fluid, identical with the black vomit, in the extremities of 
the blood-vessels, more or less of which is usually found in the 
cavity of the stomach. Occasionally, a large quantity of pure 
blood has been discovered in the stomach; this happened in one- 
eighth of the cases examined by Bally, Fran9ois, and Pariset ; 
and Cheve states in his thesis, that he observed it three times 
on the Senegal.^ Sometimes, the stomach is distended with 
gas. 

Intestines, — The appearances in the intestines often resemble 
those in the stomach ; but they are generally in a less marked 
degree. In some protracted cases, there are minute ulcera- 
tions. Jackson states, that the diameter of the intestines is 
sometimes contracted, and that intro-susception is not uncom- 
mon.^ The black matter is in some cases found only in the 

1 DuFLOT. Etudes sur la Fievre Jaime : these, a Paris. 

2 Cheve. Relation des Epideaiics de Fievx'e Jaune, qui ont regne' a Goree et a 
St Louis (Senegal) pendant I'hiveruage de 1830 : these, a Paris, 1836. 

3 Vide p. 93. 



PATHOLOGY OF THE DISEASE. 



123 



small intestines. Gillkrest has pointed out, that the glands of 
Peyer are never diseased. 

Peritoneum. — Larrey states, that in Egypt he always found 
what he considered inflammation of the peritoneum.' Numerous 
French and Spanish authors describe quantities of black blood 
as being found in the folds of the mesentery. 

The spleen is, according to most authors, frequently gorged 
with blood, and softened. 

The pancreas is seldom altered in colour, consistence, or volume. 
Dalmas, and Lazo de Perez, mention some instances, however, in 
which it was enlarged.^ 

The Liver. — The structure of the liver does not seem, as 
many have supposed, to undergo any uniform alteration, but 
is sometimes, on the contrary, quite healthy in appearance. 
The morbid anatomy of this organ, therefore, does not throw 
much light upon the pathology of yellow fever. But the appear- 
ances found on dissection, when viewed in connection with the 
alterations of the other viscera, are of some importance. Jack- 
son says, that the liver and spleen are often gorged with black 
blood, " so as to be perfectly rotten," and that generally, even in 
mild cases, it is turgid and increased in size. He describes the 
gall-bladder as being sometimes full and sometimes empty, and 
as containing bile, either thin, or thick and black, like tar or 
molasses. Gillkrest states, that during the greater part of the 
Gibraltar epidemic of 1838, the colour of the Hver was pale 
olive, or a mixture of green and yellow in ordinary cases, but lit- 
tle altered in the more malignant. In women and children, the 
tinge was paler. He found the gall-bladder diminished in size, 
and containing a minute quantity of orange-coloured, or green 
bile, and occasionally of pus. The cystic duct is reported to have 
been impervious in a few cases.'"^ 

' Larrey, (Campagnes, torn, ii.) Memoire sur la fievre jaune, Paris, 1821. 
^ Lazo et Perez. Colleccion de iiispecciones anatomicas relativas a la fiebre 
amarilla. Cadiz. 

^ I do not presume to say, that so accurate an observer as Dr Gillkrest made a 
mistake regarding this state of the cystic duct : but I have known of its having been 
declared impervious, when in a perfectly normal condition, simply from the examiner 
forgetting, that in pushing the most delicate probe up the duct from the gall-bladder, 
it is likely to meet with an impediment from a fold of mucous membrane. The 
blowing up of air through a small blow-pipe is the proper method of exploration. 



124 



PATHOLOGY OF THE DISEASE. 



Louis attaches great importance to a particular appearance of 
the liver, which he found to be the most universal of all the post- 
mortem appearances which he observed at Gibraltar. Asa similar 
appearance was met with in some of my cases ; and as I am in- 
formed, that it has been often met with at Dundee, during the 
last twelve months, his description is subjoined : — " The most re- 
markable lesion of the liver, was the alteration of its colour, which 
was more or less exactly the same in all the cases, and through the 
whole extent of the organ, with three exceptions, of which I shall 
soon have occasion to speak. This alteration consisted in a dis- 
coloration, the liver being sometimes of the colour of fresh butter, 
sometimes of a straw colour, sometimes of the colour of coffee and 
milk, sometimes a yellowish gum colour, or a mustard colour, or 
finally, sometimes an orange or pistachio colour. This discolora- 
tion was not the same through the whole extent of the liver; it was 
more marked in the left, than in the right lobe; it was also more 
uniform. In cases where the colour was uniform in the left lobe, 
there was in the right lobe a mixture of gum-yellow, orange, or 
red points, larger or smaller; or else, we found in the right lobe 
a rose tint, which did not exist in the left lobe. The cases in 
which the colour of the liver was formed by the mingling of dif- 
ferent coloured points, were rare, and this disposition was some- 
what remarkable in one of them, where the liver presented a 
mixture of yellow and green points. The last colour could not 
be considered the result of commencing putrefaction, for the 
subject was opened six hours after death. In the three cases 
referred to above, in which the discoloration of the liver was not 
universal, the right lobe preserved its natural colour throughout, 
or in its obtuse edge only. With the discoloration of the liver 
we found a more or less marked paleness, and a diminished 
quantity of blood, so that wherever this appearance of the liver 
was well marked, the sections of it were dry, and of an arid ap- 
pearance in the left lobe."^ 

The Jcidneys in general present no very remarkable alterations, 
though they are, like the liver and spleen, frequently gorged with 
blood, especially when there has been suppression of urine. Sa- 

* Louis. Anatomical, Pathological, and Therapeutic Researches on the Yellow 
Fever of Gibraltar of 1828 ; translated from the manuscript, by G. C. Shattuck, 
junior, M.D. Boston, 1839. FzWe page 117. 



PATHOLOGY OF THE DISEASE. 



125 



vuresi states, that in the fever of Martinique, — an epidemic 
characterized by much dehrium and stupor, — he constantly found 
inflammation, as well as engorgement of the kidneys. He has also 
seen the ureters contracted, and their inner surface adherent, so 
as to obliterate the canal. Rochoux maintains, that he has dis- 
covered traces of phlogosis of the kidneys in one-third of the 
bodies he examined. The urinary Uadder is often contracted 
and thickened. 

f. The Brain. 

The vessels of the dura and pia- mater, as well as the 
choroid plexus, are usually gorged with dark blood. Serous 
eff"asion is rare in some epidemics, and common in others. 
Rochoux, in describing the yellow fever of Guadaloupe, states, 
that inflammation of the membranes of the brain was seldom 
seen, and when it did occur was less severe than in Europe; but 
this statement is not confirmed by others. Amid the discord- 
ance of opinion, we can hardly hope to arrive at the truth; this, 
however, we learn, that this lesion varies in different epidemics. 
When there is coma before death, it is natural to expect hype- 
remia of the brain. Some have described softening, and others, 
hardening of the brain. The spinal canal has been found to 
contain yellow serum, especially in the lumbar and sacral regions. 
Dr Thomas of New York believes the seat of the disease to be 
in the spinal marrow, and relates ten cases in which he supposed 
that he had detected inflammation of the investing membranes. 
He mentions also, having seen in all his cases, inflammation of the 
stomach. The nerves were attentively examined by Fran9ois, 
Bally, and Pariset, but no morbid appearances were discovered. 
Cartwright, in his essay on the yellow fever of Natchez, states 
that he found the semilunar ganglion and coeliac plexus much 
altered; their neurilema and their tissue were of a deep red 
colour, and mottled with black spots. 

All these appearances are evidently the result of congestion ; 
and many of them, not observed in my dissections, would, in all 
probability, have been observed, had they been looked for. 



12G 



SEQUELAE OF THE FEVER^ 



CHAPTER IV. 

SEQUELiE OF THE FEVER. 

My opportunities of studying the sequelae of the fever have 
necessarily not been very extensive, as leisure could not be 
afforded, to watch any considerable number of patients, after 
their dismissal from the hospital. 

The post-febrile affections which I have noticed in the hospi- 
tal are, 

1. A peculiar form of ophthalmitis, usually preceded hy amauro- 
tic symptoms. 

2. Glandular swellings. 

8. Boils and cutaneous eruptions. 

4. Effusion into the hiee-joint. 

5. Sioelled legs and ankles. 

6. Pain in the feet, loith, and loithout swelling. 

7. Paralysis of the deltoid, and certain other muscles. 

8. Sloughing of parts. 

1. A peculiar form of ophthalmitis, usually preceded hy amauro- 
tic symptoms. 

This disease is particularly interesting, from the resemblance 
which it bears in some of its characters to rheumatic ophthalmia, 
and from its occurring as a sequel to a fever in which muscular 
and arthritic pains are very prominent symptoms. It has been 
described by Dr Mackenzie, in the Medical Gazette for the 24th 
of November, as a sequel of the fever now prevailing in Glasgow; 
and also by Dr Jacob and others, as having occurred in persons 
after recovering from the Dublin epidemic of 1826. 

The first case which occurred to me, I sent to Dr Watson, at 
the Eye Infirmary, from whom I first learnt, that the affection 
was prevalent in Glasgow, and had attracted the attention of 
Dr Mackenzie, the eminent oculist of that city. 



SEQUELS OF THE DISEASE. 



127 



The first person in whom I noticed this disease was a man aged 
50, who was admitted to the New Fever Hospital, on the 29th 
August, when convalescent from a second relapse, or third attack 
of the fever. He was very feeble, but made no particular complaint, 
except of slight general articular pains, and intolerance of light ; 
there was much lachrymation. Nourishing food, and a quinine mix- 
ture w^ere ordered. In a few days, as he became much stronger, he 
was removed to the convalescent ward. I heard nothing of the eye 
for some days, when, upon my proposing his dismissal, he complain- 
ed of dimness of vision, with pain in the organ and above the or- 
bit. Upon examining the right eye, the lens was found to be 
hazy, and the sclerotic to have a muddy look as contrasted with 
that of the other eye. The cornea was roughened with extremely ^ 
minute ulcers, the individual outlines of which were hardly visi- 
ble, except when looked at in a strong light and through a mag- 
nifying glass. A blister was applied behind the ear, and a dis- 
charge kept up from the surface for some days : a few drops of 
a solution of two grains of nitrate of silver in an ounce of dis- 
tilled water were daily let fall upon the open eye. Under this 
treatment, the pain entirely left him, but the ulcerations of the 
cornea showed little disposition to mend, and the blindness in- 
creased. It was in these circumstances, that the patient was 
sent to the Eye Infirmary. 

The only other persons whom I have seen with post-febrile oph- 
thalmitis were two females. In them the disease was of a much 
more acute character, the conjunctivas and sclerotics of both eyes 
being intensely injected : there was severe pain, and almost total 
loss of vision. For two or three days before the inflammatory symp- 
toms disappeared, there was amaurosis. Both were very weak. 
The treatment consisted in fomentations, leeches, the use of a 
shade, and a liberal allowance of wine. When they left the 
hospital, no visible sign of disease existed in the eyes, but there 
was still impaired though returning vision. 

The following is the most important part of the valuable me- 
moir of Dr Mackenzie: — 

" Typhus fever is sometimes followed by muscse volitantes, or 
even by amaurosis, and in some rare instances by phlebitic oph- 
thalmitis. Certainly, no febrile disease with which we have been 



128 



SEQUELS OF THE DISEASE. 



hitherto acquainted in this country is followed by such an inflam- 
matory affection of the eye, as that which I am about to describe. 
I have known the disease which is called hay fever, followed by 
intermittent ophthalmia, of iritic character. Dr Lawrie informs 
me, that remittent fever in India is sometimes followed by cor- 
neitis, and sloughing of the cornese. 

" I shall now select, from the journals of the Glasgow Eye In- 
firmary, a few cases illustrative of the affection of the eye which 
has appeared as a sequela of the remittent fever now prevailing. 
From the 8th August to the Slst October, when I finished my 
quarterly period of attendance, 86 cases of this description were 
taken on the list. The general subjects of the affection in ques- 
tion have been from 1 7 to 20 years of age ; but it has spared 
neither young children nor old people. The youngest out of the 
8 6 was 18 months old; the oldest was 56 years. The general 
character of the disease has been partly amaurotic and partly in- 
flammatory. In by far the greater number of cases, the eyes at- 
tacked had been previously healthy, but in some instances, they 
had suffered from other diseases, and in one case, they were al- 
ready in a great measure disorganized. 

" I. — Amaurosis and oplitlialmitis after remittent fever — treated 
hy leeches^ calomel and opium, helladonna, hlisters, and quina — 
complete recovery. 

"No. 18185. — Aug. 8, 1848. Margaret Spence, aged 12, was 
seized with remittent fever, which she calls influenza, nine weeks 
ago. Right eye became red three weeks ago. Conjunctiva still 
somewhat red ; pupil dilated, and does not contract readily on 
exposure to light ; vision of right eye so dim, that she does not 
see the eyes of a person sitting before her. Circumorbital pain. 
Pulse 180. — Hirud. vj ad tern. dext. — B. sulm.hydr. gr.iv. ; pulv. 
opii grj. M. ft. pulv. hor. som. sumend. — Cras mane sumat 
sulph. magn. ^ss. 

" 9^A. Less pain ; vision rather better. — Extr. hellad. ad palp, 
dextr. — B. suhn. liydr. gr.xij\ opii gr.ij, sacc. alb. 9/ — M. opt. 
et divide in pulv. xij. Cap. j Sd qq. liord. 

" \^tli. More pain. — Hirud. vj ad palpehr. dext. 

" \2th. Eye easier, and less red. Vision rather better. Eight 



SEQUELiE OF THE DISEASE. 



129 



cornea more than naturally flexible. — Re^p. sulph. mag. — Vesicat. 
pone aur. dextr. 

" IZth. Pain subsides. Vision improves. 

*' \ 5tli. Sees best when she looks over her nose. 

" IQth. Rep. helladon. — Vesicat. ad tern, dextr. 

'•''VJth. Pupil widely dilated, and vision consequently more 
obscure. 

" l^tli. Pupil not so widely dilated. Vision improved. No pain. 
"2]s^. Gap, pulv. subm. liyd. et opii j. — Bep. vesicat. pone 
aur. dextr. 

Vision much improved ; pupil of natural size. Has 
caught cold, and complains of pain in the chest. — Pedilm. tepid. 
'Vesper e. — Omit, medicamenta. 

" 28th. Hirud. vj ad pectoris partem dolentem. — Cap. ol. ri- 
cini ^ss. 

" 29th. Relieved by the leeches. 
" SOth. Is confined with measles. 

" Sept. 6th. Dimness of sight of the right eye still continues. — 
Vesicat. parvum ad temp, dextr. 

" 132^^. Bowels loose. — Cap. quam primum tinct. opii gtt. x. 
R. opii gr.j. Cretw ppt. zij. M. et div. in pulv. xij. Cap. j post 
sedes singidus liquidas. 

" \6th. Bowels still loose. 

" 2Uh. Cap. sidph. quin. gr.j. ter in dies. 

" Oct. \^th. Says her eye is perfectly well. — Omit, remedia. 

*' II. — Retinitis and amaurosis after remittent fever — complete cure 
hy leeches., calomel and opium., hlisters^ andquina. 

"No. 13186.— Jw^. 8, 1843. Margaret Paterson, aged 11, 
had remittent fever in the end of June. Eight days ago, the right 
eye appeared red. The conjunctiva and sclerotica are moderate- 
ly injected; the iris is of a green hue ; the pupil somewhat dilat- 
ed, and very sluggish; the retina retains merely a perception of 
light and shade. No pain of head; pulse 120; tongue clean. — 
Hirud. vj ad temp, dextr. — R. suhm. hydr. gr.iv^ pulv. opii gr.j. 
M. ft. pulv. hor. som. sumend. — Cras mane sulph. magn. 

" 9th. Tells a pen and other objects with right eye. — Rep. pulv. 
et sulph. magn. — Vesicat. pone aur. dextr. 

9 



130 



SEQUELS OF THE DISEASE. 



" lO^A. Eye painful; much lacrymation ; vision again worse. — 
Hirud. vj ad palp, dextr. 

" IWh. Symptoms subside. Sees best when she looks dextrad. 
R. suhn. Jiydr. gr.xij.^ puh. opii gr.j\ sacc. alb. 9/ 31. div. 
in pulv. xij. Cap. j o. n. 

" 15th. Vesicat pone aurem dextr. 

" \^ih. Has by mistake been taking a powder thrice a-day. — 
Cap. pulv, jo. n. tantum. 

" 22<^. Right pupil not so much expanded as left. Vision im- 
proves slowly; is still most defective when she looks sinistrad. 

" 2bt]i. Vision continues to improve. — Omit. pulv. suhn. Jiydr. et 
opii. — Cap. sulph. quin. gr.jter in dies. 

" 21th. Still improves. 

" Sept. \st. Vision much improved. 

" ^d. ^o\yQ\BQoiA.nQdi.~Cap. pidv. jalap, comp.gr. xv. 

" Qth. Cont. quina. 
12th. Continues to improve. 

" 2Qth. Says her eye is quite well. 

" III. — Iritis after fever — treated with quina, leeches, and vesi- 
cation. 

" No. 1S22B.— Aug. 26, 1843. Catherine M'Donald, aged 55, 
has been labouring under the epidemic fever now prevalent. 
Right eye affected with iritis. Iris discoloured; pupil hazy; vision 
dim; nocturnal pain in eyeball, preventing sleep. Pulse 96, 
small. — Belladon. ad palp, dextr. — Cap. sulph. quin. gr.ij Svd 
qq. hord. 

2^th. Pain not relieved. — Hirud. vj ad palp, dextr. — Cap. ol. 
ricini %j. — Hodie omit, quina. 

" Sept. 1st. Eye easier; vision clearer. 
" Sth. Vesicat. pone aur. dextr. 
" lUh. Much improved. 



SEQUELyE OF THE DISEASE- 



1.31 



*' IV. — -Ophthalmitis after fever — treated hy venesection, leeches, 
calomel and opium, belladonna, vesication, and quina — muscce 
volitantes left. 

" No. 1S2D4^,—Sept. 7, 1843. James Nairn, aged 18, had 
epidemic fever in J uly last. After twelve days, had a crisis, but 
relapsed after other four days, with shiverings, and pain in the 
bowels. Eleven days ago, symptoms of iritis affected right eye. 
Sclerotica injected; iris, naturally hazel, of a darker colour than 
that of opposite eye; pupil contracted and irregular; sight so 
dim that he cannot read the large letters on the Infirmary card. 
Supra-orbital pain, increased during the night, and preventing 
sleep. Has apphed four leeches, without relief. — Venesectio. 
Belladon. ad palp, dextr. Cap. pilulam cum subm. hydr. gr.ij, opii, 
gr.ss. Svd qq. hord. 

8th. Pain relieved; pupil somewhat dilated; vision rather 
clearer. 

" 9th. Hirud. vj ad temp, dextr. 

" ] ^th. Gutta sol. nitr. argent, (gr.x ad aq. 7)j) ad ocid. dextr. 
Vesical, pone aur. dextr. 
" \1th. Eye easier; pupil more dilated. 
" 14M. Much improved. 

" Vjth. Mouth begins to be affected; eye much better. — Cap. 
pilulam in dies tantum. 

" 20ifA. A musca volitans before right eye. In other respects 
better. 

" 25^A. Omit. pil. — Ca'p. sulph. quin. gr.j ter in dies. 

" Oct. Qth. Eye free from inflammation; still complains of 
muscse volitantes before right eye. 

" 2^th. Says that the vision of right eye is as clear as that of 
left, but he is still troubled with muscse volitantes. — Omit, quina. 

" V. — Epidemic fever — abortion — iritis — cured by belladonna, 
quina, and purgatives. 

" No. IZ^m.—Septemher 9, 1843. Mary Quin, aged 20, was 
seized with epidemic fever about a month ago. This was follow- 
ed by an abortion in the fourth month. Eyes have been affected 
with slight rheumatic iritis for twelve days. Pulse 96. Bowels 



132 



SEQUELS OF THE DISEASE. 



regular. — Belladon, ad ]palpebras. — Ca'p. sulph. qnin. gr.j octava 
qq. hord. 

" llth. Right pupil a little dilated, and vision of that eye some- 
what clearer. — Cap. pulv. jalap, comp. Zss. 
" 12^7^. Right pupil more dilated. 
" 14^th. Inflammation abates. 
" 18th. Bjcp. pulv. pxirgans. 

" VI. — Epidemic fever ^ followed ly capsulitis of the crystalline and 
cornea. 

" No. \^1^^.—Bept. 10, 1843. John Collins, aged 31, a tra- 
velling dealer in stoneware, had the epidemic fever about six 
weeks ago. Eight days ago, when travelling by railway, sup- 
posed some particles of coke to have got into his right eye. Con- 
junctiva and sclerotica of that eye very slightly injected; iris of 
a lighter colour than that of opposite eye; both irides greenish; 
makes no complaint of left eye, the vision of which is good ; right 
pupil natural in size; its motions limited and slow; vision of right 
eye so dim that with difficulty he tells one finger from another 
with it, when held close before him ; pupil appears slightly muddy, 
and on concentrating the light upon it with a convex lens, a red- 
dish wreath appears on the anterior crystalline capsule, just with- 
in the verge of the pupil; says that for two nights, the pain was 
pretty severe in right eyeball. Pulse 84, small; tongue white. 
— Belladon. ad palp, dextr. — Pulv. purg. '3/. 

" llth. Right pupil widely dilated; the red wreath is now situ- 
ated half way between the centre and the circumference of the 
pupil; a number of minute spots visible on the internal surface 
of the cornea, especially towards its lower edge; vision consider- 
ably clearer. — Cap. pil. hydrarg. j m. et v. 

" VII. — Epidemic fever followed ly ophthalmia of catarrho-rheu- 
matic character., relieved hy venesection^ helladonna^ purgatives^ 
and calomel and opium: 

" No. lS282.—Septe7nher 19, 1843. Ann Morrison, aged 41, 
had^epidemic fever in July, since when has been constantly trou- 
bled with pain in left side of head. Left eye affected with oph- 



SEQUEL.E OF THE DISEASE. 



133 



thalmia of catarrho-rheumatic character. Pulse 72 ; tongue 
foul; bowels costive; no sleep, from the hemicrania. Applied 
four leeches with some relief. — Belladon. ad 'palp. sinistr. Vene- 
sectio. Pidv. purg. 9/. 

" 20th. Blood bufFy; pain much relieved; pupil irregularly ex- 
panded. — Cap. pil. cum suhm. Jiydr. gr.ij, et opii gr.ss.^ m. et v. 

" 2\st. Eye free from redness. 

" 23c?. Cap. sulpli. magnes. Zj.—Hodie omit. pil. 

" VIII. — Epidemic fever — premature labour — amaurosis and 
ophthalmia — cured hy hleeding^ mercury., blisters, and belladonna. 

" No. 1S290.— Sept. 20, 1843. Catherine Auld, aged 28, was 
seized with the prevailing fever two months ago. Relapsed, and 
had a premature confinement at the eighth month. Since her 
convalescence, sight of both eyes has become dim, and the right 
eye is inflamed. — Hirud. vj ad temp, dextr. 

" 21s^. Hemicrania on right side. — Belladon. ad palpebras. 
Venesectio. — Cap. pil. cum subm. hydr. gr.ij, et opii gr.ss., m-. et 

" 22d. Pain relieved. Right pupil irregularly dilated, being 
tagged to capsule at nasal edge. 

" 2Sc?. Pain increased. — Bep. venesectio. 

" 24ith. Pain relieved. — Omit. pil. — Vesicat. pone aiw. dextr. 

" %^th. Cap. ol. ricin. \j. 

" 27th. Hirud. vj ad temp, dextr. 

" 29^A. Eye improves. Still complains of supra-ocular pai©. 

— Vesicat. ad temp, dextr. 

" October 2. Cap. pil. j in dies tantwm. 

" 15M. No pain nor inflammation. A lace- work of muscse voli- 
tantes before each eye, which, however, does not prevent her from 
reading small type. — Cap. sulph. quina gr.j terin dies. Omit. pil. 

" IX. — Epider.iic fever — iritis — cured by combination of quina 
and calomel. 

" No. 13330.— Oc2f. 5, 1843. Agnes JefFray, aged 17, was 
seized with the prevailing fever six weeks ago. Being convales- 
cent after a relapse, began to sew, which has brought on inflam- 
mation of right eye. Iris of a green colour; pupil contracted; 



134 



SEQUELAE OF THE DISEASE. 



vision dim. — Belladon. ad paljy. dextr. — R. sulph. quinines, suhm. 
Jiydr.^ dd gr.ccij, sacc. alb. 9/. 31. et div. in pulv. xij. Cap.j 
odam qq. hord. 

" &h. Pupil widely dilated; eye easier. 

" 1th. Eye free from inflammation. 

" lOth. Continues to improve. 

" X. — OpUhalmia interna after fever — yields slowly and imper- 
fectly to quina. 

" No. ISSSS.— October 8, 1843. William Armour, aged 17, 
is a fortnight convalescent from epidemic fever; left iris presents 
a darker colour than natural ; pupil rather hazy ; sclerotica 
slightly injected; vision dim. — Belladon. ad palp, sinistr. — Cap. 
sulph. quin. gr.j ter in dies. 

" 10th. Cont. remedia. 

" 12^A. Has had more pain. — Hirud. vj ad palp, sinistr. 

" l^th. Still occasional attacks of pain; vision improves. — 
Cap. sulph. quin. gr.ij Svd qq. hora. 

" 22ci?. Pain entirely gone; vision of left eye still very dim. — 
Cont. bellad. et sulph. quin. 

" 27^A. Vision does not improve. — Omit, sulph. quin. — Cap. pil. 
subm. hydr. gr.ij, et opii gr.ss. octavd qq. hord. 

" 29^A. Vision clearer, but still so imperfect that he cannot 
with left eye make out characters an inch long; iris of a greenish 
hue, and bolstered forwards towards cornea; eyeball preternatu- 
rally flexible. — Abrad. latus. cap. sinistr. et appl. vesicat. pone 
aurem. — Cont. belladon. et pilulw. 

" XI. — Ophthalmia interna after fever — passes from right to left 
eye — yields slowly to depletion, mercury, quina, belladonna, and 
'vesication. 

" No. 13339.— OdoS^r ll^fA, 1843. Grace Arnott, aged 15, 
is two months convalescent from epidemic fever; about ten days 
ago, right eye became inflamed; sclerotica intensely injected; 
iris of a dull green colour ; pupil of natural size, moveable, but 
very hazy; vision so dim, that with right eye merely perceives 
light and shade ; pulsatory pain in eyeball ; no circumorbital 



SEQUELS OF THE DISEASE. 



135 



pain; pulse 84; occasional rigors; has been working in a cotton 
mill, and in a high temperature. — Hirud. -y/ circum oculum 
dextr. — Cap. pilulam cum suhm. hjdr. gr.ij^ et opii gr.ss., octavo, 
qq. hord. 

" '12th. Belladon. ad palp, dextr. — Ahrad. latus dextr. capit. et 
applic. vesicat. 

" loth. Venesectio. 

" I4}th. Blood not buffy; pain not relieved; pupil irregularly 
dilated. — Cap. sulph. quin. gr. octavo, qq. hord. — Cont. pil. 

loth. Bowels bound. — Cap. quam primum sulph. magn. — 
Cont. quin. et pil. 

" 16#A. Painless; vision clearing ; four or five stools, from 
the salts ; pupil somewhat dilated ; irregular ; rather clearer. 

" Vlth. More pain and lacrymation during the night; vision 
continues rather clearer. — Omit. pil. 

" l^th. Bep. hirud. 

" l^th. Vesicat. ad temp, dextr. 

" 20th. Mouth sore. 

" 21sif, Through the night, left eye became affected with pain 
and redness ; vision of it somewhat dim ; right eye improves ; 
had rigors during the night, when the pain shifted from the right 
to the left temple. 

" 22d. Left pupil widely dilated ; right eye improves. — Bella- 
don» ad palp, dextr. tantum. 

" 2Zd. Appearance of right eye greatly better. 

" 2Uh. Left eye more affected, being red and painful. — Hirud. 
vj circum ocidum sinistr. 

" 25^A. Pain of left eye relieved by the leeching; right eye 
free from redness; iris more of its natural colour; pupil irregu- 
larly dilated, presenting two tags to capsule at its upper edge. — 
Cont. sulph. quin. et helladon. 

2^th. Both pupils widely dilated; right still irregular; 
vision of right eye still very dim; no pain; no rigors. 

" 29^A. Eyes free from redness and pain ; vision of right eye 
so dim that she cannot make out letters an inch long ; with left 
eye reads the smallest type on infirmary card; right pupil still a 
little irregular; left cornea preternaturally flexible ; mouth well. — 
B. suhm. hydr. gr.xij^ sulph. quin. gr.xxiv. — M. et div. in pulv. 
xii. Cap. j octavd qq. hord. — Cont. helladon. — Omit. alia. 



136 



SEQUELS OF THE DISEASE. 



XII. — Epidemic fever ; three relapses, followed hy amau- 
rosis and ophthalmitis; symptoms yield to quina, leeches, and mer- 
cury. 

" No. 13346.— 162f/^ Octoler 1843. John Harvey, weaver, 
aged 44, had epidemic fever twelve weeks ago ; had three re- 
lapses; found vision of left eye to become dim about a fortnight 
ago; it is now so deficient that he merely perceives light and 
shade with it; four days ago the eye began to get red; sclerotica 
much injected ; a narrow whitish ring between sclerotica and 
cornea ; cornea rather hazy ; iris greenish ; pupil contracted, 
irregular, and very hazy; supra-ocular pain increased during the 
night, and at that time preceded by rigors ; much lacrymation ; 
muscse volitantes ; puke 72 ; bowels regular ; thinks the affec- 
tion of his eye arose from his going into his cold shop to work. 
— Bdladon. ad palp, sinistr. — Cap. sulph. quin. gr.iij, octavd 
qq. hord. 

" 1 7th. Eye easier ; less lacrymation. 

18t/i. Vision rather cleaTer.-^ Vesical, pone aur. sinistr. 
" 19th. Symptoms abate. 

" 21 St. Supra-orbital pain still considerable; vision clearer. — 
Hirud. m ad palp, sinistr. 

" %Zd. Pain isomewhat abated since the leeching ; pupil still 
contracted, and vision dim. — Vesical, parv. ad part, frontis do- 
lent. 

" %5th. Pain relieved ; eye remains in much the same state. — 
Cap. pil. subm. hydr. gr.ij, et op)ii gr.ss., octavd qq. hord. — Omit, 
quin. Cmit. belladon. 

" ZOth. Eye improves ; with some difficulty makes out letters 
an inch long ; mouth sore. — Cap. pilulam in dies taniim. 

" XIII. — Ophthalmitis after fever; being neglected, ends in 
synechia posterior, and almost total loss of sight ; slow improve- 
ment under the use of quina and calomel. 

No. 13355.— 18^A October, 1843. Bridget Carey, aged 50, 
had epidemic fever four months ago ; three months ago, sight 
began to fail; both pupils are irregular, and the lenses very hazy; 
vision, especially of the left eye, nearly limited to a perception of 



SEQUELS OF THE DISEASE. 



137 



light and shade; gropes like an amaurotic, and has a most melan- 
choly expression ; to relieve the burning heat of eyes, poulticed 
them for two months; this has produced entropium of each 
lower eyelid ; pain in the temples, especially during the night ; 
tongue clean ; bowels bound ; back of pharynx ulcerated ; says 
the throat has been sore since before taking the fever ; has used 
only purgatives, such as salts and castor oil. — Belladon, ad palpe- 
hras. — Vesicat. ad tempora. — B. suhn. liydr.^ sidpli. quin. dd gr. 
eocciv. M. et div. in pulv. xij. Cap. i octavd qq. hord. 

" 19th. Pain in head somewhat less; bowels griped; a stripe 
of court-plaster applied across each lower lid. 

" 20th. Complains much of pain in left side of head. 

*' 21st. Entropium less troublesome. 

" 2Sd. Mouth sore ; pain subsiding ; vision appears to be sta- 
tionary. — Omit. suhm. hydr. — Cont. quina. 

" 24^th. Gargarism. alumin. — Cap. h. s. puh. dover. gr.xij. 

" 2^th. Bowels loose. — Cap. ol. ricin. zj. Cont. quin. et pulv. 
dover. 

" 2Qth. A good night ; pain of head much less ; there appears 
to be no improvement in the eyes. 

" 2Sth. Right pupil irregularly dilated ; distinguishes a pen 
and other objects w^ith right eye, being the first sign of improve- 
ment in vision since her admission. — Cont. hellad. quin. et pulv. 
dover. 

" 29th. Is much less troubled with the entropium ; both pupils 
very irregular, presenting numerous adhesions to capsules ; ap- 
pears to have merely perception of light and shade with left eye ; 
vision of right eye improves ; still complains of pain in left side 
of head. — Ahrad. latus cap. sinistr. et appl. vesicat. ad partem do- 
lentem. — Cont. alia. 

" ZOth. Pain relieved by the blister. 

" XIV. Remittent fever., followed hy ophthalmitis ; cured hy 
belladonna^ purging^ leeches, and mercury. 

No. 13375.— 252^A October, 1843. Jane M'Naught, aged 13, 
was seized with remittent fever five weeks ago ; for eight days 
past the left eye has been inflamed ; pupils irregular ; vision 

T 



138 



SEQUEL.E OF THE DISEASE. 



dim; nocturnal pain; bowels bound. — Belladon. ad palp, sinistr. 
— Ptilv. purg. gr. oov. 

" 26^A. Three stools from the powder ; no sleep on account of 
the pain. — Cap. pulv. dover. gr.viii h. s. 

" 27th. A rather better night ; sclerotica very vascular. — 
Hirud. m ad palp, sinistr. Cap. pil. cum subm. liydr. gr.ij; et opii., 
gr.ss. mane et vespere. 

" 2^th. Eye easier ; no pain in the head ; a good night ; scle- 
rotica less injected ; pupil pretty clear ; vision more distinct ; 
bowels regular. — Cont. helladon. et pilul. — Vesicat. pone our. 
sinistr. 

" SO^A. Pupil widely dilated. — Ahlue helladon. 
" Nov. \st. Continues to improve. 

" XV. — Severe ophthalmitis after remittent fever ; relieved ly 
venesection and mercury. 

" No. 13378.— 28^A Octoler 1843. Hugh Leech, aged 26, was 
seized with remittent fever about eight weeks ago. First attack 
lasted about ten days; the remission, three days; and the second 
attack seven days. During his convalescence was sleeping in a 
very uncomfortable place, and much exposed to cold. On the 
morning of the 25th, awoke with great pain in right eye. The 
sclerotica is intensely red, the iris has assumed a green colour, 
the cornea is slightly hazy, and the pupil very much so; it is 
considerably contracted, and the vision of the eye is limited to a 
perception of light and shade; pulse 108; tongue white. Under- 
went no treatment for the fever. — Belladon. ad palp, dextr. Vene- 
sectio. — Cap. pulv. suhm. hydr. gr.ij., et opii. gr.ss., octavo, q. q. 
hord. 

" 2^th. Blood somewhat buffy; felt relieved by the bleeding; 
pulse 84; sclerotica not so red; pupil not so hazy; vision clearer. 
— Ahrad. latus capit. dextr. et appl. vesicat. pone aurem. 

" Z^th. Blisters have been applied behind both ears. 

" Nov. 1. Mouth sore. Can read the numbers on the tickets, 
which are about an inch long. — Cap. pulv. vesp. tantum. h. s. cap. 
pulv. dover. gr.viij. 



SEQUELS OF THE DISEASE. 



1S9 



*' XVI. — Remittent fever — abortion — o^litlialmxtis — relieved hy 
leeching and mercury, 

"No. 13379.— 28zJA Octoler, 1843. Flora Reynolds, aged 
22, was seized with epidemic fever six weeks ago. Says the at- 
tack lasted two weeks, and that she had no relapse. Five weeks 
ago, had a miscarriage at the third month, with excessive dis- 
charge. Menstruated a week ago, and more profusely than 
common. Says her feet and legs became dropsical during her con- 
valescence. Was sleeping in an apartment with broken windows, 
and ten days ago, was attacked with pain in left eye, which now 
presents the usual symptoms of ophthalmitis post febrem, the 
sclerotica being injected, the iris discoloured, and vision very dim. 
No sleep, from hemicrania; pulse 84; tongue clean; bowels re- 
gular. — Hirud. "cj ad palp, dextr, — R. subm. Iiydr. gr.v; puh. 
dover. gr.xij, — M. ft. pulv. h. s. sumend. eras mane^ sulph. magnes. 

¥• 

"30^A. Pain almost gone. Vision clearer. — Belladon. ad palp, 
sinistr. Cap. pil. subm. hydr. gr.ij\ et opii gr.ss.^ octavo, q. q. hora. 

" Remarks. — The cases above related may serve to give an 
idea of the affection of the eyes, which has in so many instances 
followed the fever now prevailing, and of the treatment which I 
have employed for it. I have generally called the disease oph- 
thalmia post febrem^ but perhaps, the appellation of ophthalmitis 
post-febrilis is more correct. 

" Statistics. — The following are a few statistical facts, which 
may be worthy of notice: 

" Out of the 36 cases which I treated in August, September, 
and October, 27 occurred in females, and only 9 in males. 

" The following were the ages of the 36 patients: below ten, 2; 
from ten to twenty, 17; from twenty to thirty, 9; from thirty to 
forty, 2; from forty to fifty, 3; from fifty to sixty, 3. 

"In 18 of the cases, the right eye only was affected; in 10, the 
left only; and in 8, both eyes, either together or consecutively. 

" The attack of ophthalmitis occurred at various periods from 
three to sixteen weeks from the commencement of the fever. In 
several cases it came on about two weeks after convalescence 
from the relapse, but generally somewhat later. 



140 



SEQUELS OF THE DISEASE. 



" The very same disease of the eye occurred after the DubUn 
epidemic of 1826, and was described by Mr Hewson/ Dr Reid,^ 
Dr Jacob,^ and Mr Wallace.* The last-mentioned author has 
remarked the greater liability of the right eye to be affected than 
the left. ' Of forty cases,' says he, ' which I have noted, there 
were only four who had the disease in the left eye, and only two 
had it in both."* Out of the ten cases in which it happened to 
me to observe it in the left eye, seven were females. The attack 
is generally traced to a draught of cold air during the night; it 
is probably the eye which is exposed which becomes affected, 
while that belonging to the side on which the patient rests, 
escapes. 

" Dr Jacob has remarked, that the disease occurs much more 
frequently in young than in old persons. Of thirty cases in which 
he noted the ages, three only were above 25. He also met with 
it more frequently in females than males. In the majority of the 
cases seen by him, the inflammation made its appearance within 
six weeks, or two months after recovery from the fever; in some 
instances, however, it appeared before the patients left the hos- 
pital, and in others, not for four, five, or even eight months. 

" Symptoms. — The character of the disease appears to be, in 
the first instance, that of congestion, followed by inflammation 
of the internal parts of the eye, and especially of the retina, pro- 
ducing great imperfection of sight. This is succeeded by evident 
inflammation of the iris and sclerotica; the disease extends to 
the capsule of the lens, and sometimes to the lining membrane 
of the cornea ; there can be little doubt but that the choroid is 
also inflamed; while the conjunctiva remains in general but slight- 
ly affected. 

" The part which the sclerotica takes in the disease is plain 
enough, from the intense injection of the blood-vessels which lie 
on its surface, and which, derived from the muscular and ante- 
rior ciliary arteries, are seen running in radii towards the cornea. 
The change of colour in the iris, the contracted state of the pu- 
pil, and the tags of adhesion between the edge of the pupil and 

' Observations on the History and Treatment of the Ophthalmia accompanying 
the Secondary Forms of Lues Venerea, pp. 34, 109. London, 1814. 

» Transactions of the Association, &c. vol. v. p, 294. ^ Ibid. p. 468. 

* Medico -Chirurgical Transactions, voL xiv. p. 286. London, 1828. 



SEQUELS OF THE DISEASE. 



141 



the capsule of the lens, show the part which the iris takes in the 
disease. The internal membrane of the cornea, and the anterior 
crystalline capsule, especially the latter, are extremely muddy, 
showing their participation in the inflammation. The whole walls 
of the aqueous cell seem, in some cases, as if coated with a thin 
layer of lymph, of a yellowish-green colour. The great deficiency 
of sight is not explicable from the mere muddiness of these parts, 
and is, besides, often the earliest symptom of the disease, show- 
ing an affection of the retina. At an early period, the pupil is 
sometimes dilated, and does not become contracted till the in- 
flammation embraces the iris. If not promptly combated by the 
appropriate remedies, the cornea and sclerotica become preter- 
naturally flexible under the pressure of the finger, showing that 
the disease has extended to the vitreous body. In one case, I 
found the cornea very flexible in the amaurotic stage, before 
there was any appearance of inflammation. 

" At the commencement, it is possible, that only the central 
artery of the retina, and the vasa longa of the hyaloid, may be 
affected. The irritation and injection speedily spread, in all like- 
lihood, to the short, as well as to the long ciliaries; to the ves- 
sels of the ciliary processes, and of the zonula Zinnii; to the 
vasa brevia of the hyaloid, the vessels of the anterior crystalline 
capsule, and those of the lining membrane of the cornea; and to 
the sclerotic network. 

" The lacrymation is very considerable, and seems to be con- 
nected, not so much with the state of the conjunctiva, as with 
the pain in the interior of the eye-ball. The severe pain in and 
round the eye, aggravated during the night, is exactly similar to 
what attends rheumatic and syphilitic ophthalmia, and may 
partly be ascribed to the pressure exercised upon the ciliary 
nerves within the eye, by the inflamed parts, partly regarded as 
a direct neuralgic affection, such as we often meet with in the six 
branches of the fifth nerve which emerge from the orbit, when 
there is no evident inflammation present. It is, in general, only 
after the iris and sclerotica have taken part in the disease, that 
the patient complains of the ocular and circum-orbital pain. So 
long as the disease is confined to the retina there is little or no 
pain. Hence the patient is less alarmed than he should be, by 
the mere dimness of sight, which, indeed, from only one eye being 



142 



SEQUELS OF THE DISEASE. 



generally affected, may scarcely attract his attention. Even 
photopsia, in the early stage, is not much complained of ; in the 
last stage, muscse volitantes form a constant symptom. 

" Although, in by far the greater number of cases, all the tex- 
tures of the eye suffer in this disease, on which account it may 
be designated as an ojihthalmitis^ it sometimes happens, that the 
inflammation is confined to one or two textures only. Thus in 
Case 6, the anterior crystalline capsule and the lining membrane 
of the cornea only were visibly affected with inflammation. 

" The pulse varies from 84 to 120. Frequently rigors occur. 
The tongue is generally clean and moist. The pain entirely pre- 
vents sleep. 

" Diagnosis. — The present disease is much more extensive, in 
respect to the number of textures affected, and much more inten- 
sive, in so far as the morbid action which is at work is concern- 
ed, than rheumatic ophthalmia, or rheumatic iritis; to which, 
however, in many particulars, it bears a resemblance. Yet, along 
with postfebrile ophthalmitis, we have neither the bounding pulse, 
the hot skin, nor the white and loaded tongue, which attend in- 
flammation of the sclerotica and iris from mere exposure to cold. 
Neither is the blood drawn from a vein so buffy. The pain is not 
less distressing. Vision is much sooner, and much more serious- 
ly involved. 

" Mr Wallace considers tliis affection of the eye as bearing so 
very striking a resemblance to syphilitic ophthalmia, that the one 
cannot be distinguished from the other, without particular atten- 
tion to the history of the case. The absence of the tawny-red- 
dish border which surrounds the pupillary margin of the iris, and 
there being tubercles on the iris in postfebrile ophthalmitis, will 
serve to distinguish the two diseases. 

" The acuteness of the present disease will discriminate it from 
scrofulous iritis, to which, particularly in the appearance of the 
lens, it bears considerable resemblance, as well as in the degree 
in which the retina is affected. 

"In some instances, postfebrile ophthalmitis bears a considerable 
resemblance to catarrho-rheumatic ophthalmis. Onyx, so frequent 
in the latter disease, I have not witnessed in the former. In one 
case I observed a considerable portion of the conjunctiva corneae 
ulcerated, but never the ulcer which affects the proper substance 



SEQUELS OF THE DISEASE. 



143 



of the cornea, and which is so characteristic of the catarrho- 
rheumatic disease. 

" The disease to which postfebrile ophthalmitis bears the near- 
est resemblance is sympathetic ophthalmitis, which results so 
frequently from incised and lacerated wounds of the edge of the 
cornea and sclerotica, and consequently of the annulus albidus of 
the opposite eye. The cause of the great similarity is, that in 
both cases the inflammation commences in the retina, advances 
to the iris, embraces all the internal textures of the eyeball, and 
ends, if neglected, in closure of the pupil, opacity of the crystal- 
line, softening of the globe, and insensibility to light. The 
slightest inquiry into the history of the case will in either instance 
elucidate the origin of the affection. 

" Stages. — Mr Wallace has described this disease as present- 
ing two stages ; the first amaurotic, and the second inflammatory. 
The cases above detailed sufficiently iflustrate the accuracy of Dr 
Wallace's description. ' During the first stage,' says he, 'there 
exist amaurotic symptoms alone ; and in the second stage, to the 
amaurotic symptoms are superadded the symptoms of inflamma- 
tion. The length of time that the amaurotic symptoms exist be- 
fore the occurrence of external redness, or of the visible symptoms 
of inflammation, is extremely uncertain, as also the period after 
fever at which the amaurotic symptoms commence. On many 
occasions the amaurotic symptoms, particularly a slight dimness 
of vision, with muscse voHtantes, have commenced at or even be- 
fore the time of convalescence from fever, and yet the inflamma- 
tory stage has not supervened for weeks or even months ; while 
on other occasions the dimness of vision has not commenced for 
several days, weeks, or even months, after the febrile attack, and 
has then been immediately followed by the symptoms of inflam- 
mation. It is to be particularly observed, that I have never seen 
a case in which, upon strict inquiry, amaurotic symptoms, more 
or less strongly marked, have not preceded the inflammatory 
symptoms. This is, in fact, one of the most remarkable charac- 
ters of the disease. It is also to be noticed, that a similar dis- 
tinction of symptoms is observable during amendment, for it uni- 
formly happens, that the inflammatory symptoms subside a longer 
or shorter time before the amaurotic symptoms disappear, and 
often before they are diminished in severity.' 



144 



SEQUELiE OF THE DISEASE. 



" The first and second cases which I have related, bore, not 
merely at the commencement, but all along, much more the as- 
pect of amaurosis than of ophthalmitis. In one case which I saw, 
the patient was suddenly struck blind of the affected eye. In 
another case, already referred to, along with amaurotic symptoms, 
the cornea had become flexible, and, no longer apprehensive of in- 
flammation supervening, I had commenced the use of quina and 
blisters, when suddenly pain and redness set in. I have met with 
several cases in which, for days, the principal symptoms have 
been pain in and round the eye, and dimness of sight. In other 
cases, there has been redness of the eye from the very commence- 
ment. 

" Predisposing and exciting causes. — That an opportunity is left 
for the disease of the eye by the fever is plain ; there may even 
be grounds for suspecting that the fever may have left the circu- 
lating fluids in an altered state, favourable for the production of 
the local complaint. However this may be, the affection of the 
eye is generally traceable to some exciting cause, and especially 
to cold. Sleeping in an apartment with broken windows, work- 
ing in a cold damp shop, and washing the head with cold water, 
are mentioned in the cases as exciting causes. Using the eyes 
too early in sewing is another. 

" Prognosis, — The recovery is tedious. In the majority of 
cases two months of uninterrupted and careful treatment has 
been necessary to effect a cure. That the disease, without any 
treatment, will wear itself out, is true ; but the eyes will be left, 
as in Case XIII., useless, from the contracted and adherent state 
of the pupil, and the amaurotic condition of the retina. If trifled 
with^ the cure will be imperfect ; synchia posterior, muscse voli- 
tantes, and other irremediable sequelae, remaining. If taken 
early, and treated vigorously, a complete cure may be prognosti- 
cated. Recovery is much more speedy and complete in young 
subjects ; in adults it is more tedious. 

" Treatment. — ] . Depletion. The w^an appearance of many of 
the patients, the smallness of their pulse, and the state of general 
debility in which they are, might tend to deter from a use of the 
lancet. I am satisfied, however, that we can rarely, with safety, 
dispense with this remedy. The blood, drawn from a vein» is 
only in a few cases buffy. Often it is difficult, from syncope com- 



SEQUELS OF THE DISEASE. 



145 



ing on, to obtain more than a few ounces from the arm. When 
this is the case, leeches to the temples, and round the eyes must 
be had recourse to. 

" If depletion is neglected, the recovery is very slow and uncer- 
tain ; adhesions form, and cannot be got rid of, and vision con- 
tinues imperfect. We must not be regulated by the pain alone, 
in taking away blood. Nothing relieves the pain so strikingly 
and effectively as venesection ; but the state of the eye, indepen- 
dently of the pain, demands the taking away of blood. We should 
not even wait for the inflammatory stage of the disease, but re- 
lieve the congestion, on which the amaurotic symptoms depend, 
by the employment of depletion. 

" Some cases, especially in children, I have trusted to leech- 
ing ; but in adults, venesection is almost always necessary. I 
have not used arteriotomy, nor cupping, but have no doubt of 
their efficacy. 

" 2. Purgatives. — The tongue being generally clean, and the 
bowels regular, there seems to be little demand for purgatives. 
At the same time, I have found them of considerable use in the 
course of the treatment. Sulphate of magnesia, castor oil, and 
compound powder of jalap, are those I have most employed. 

"3. Mercury. — I am decidedly of opinion, that the safest and the 
most effectual plan of cure embraces the use of calomel with opi- 
um, exactly as in the treatment of rheumatic or syphilitic iritis. 
This view of the matter is confirmed by the testimony of Mr 
Hewson, who seems to have trusted to opening the temporal ar- 
tery, and giving a dose of three grains of calomel with half a grain 
of opium each night. Dr Jacob, also, found the use of mercury 
so certain and decisive in this affection of the eye, that he trust- 
ed to it almost exclusively. He gave two grains of calomel, and 
a quarter of a grain of opium thrice a-day. The mouth should 
be made sore, but not too suddenly, lest we be obliged to omit 
the medicine too prematurely. 

"4. Belladonna. — The dilatation of the pupil is an essential part 
of the treatment. This is to be effected by liberally smearing the 
eyelids and eyebrow with the moistened extract of belladonna, 
morning and evening ; directing the patient to renew its activity 
from time to time, by re-moistening it with his finger dipped in 
water. 

u 



146 



SEQUELAE OF THE DISEASE. 



" 5. Counter-irritation. — Considerable benefit is derived from 
blisters to the temples and behind the ears, after due employment 
of depletion. They aid in removing the pain, lessening the inflam- 
mation, and recalling the power of vision. 

" 6. Cinchona. — Mr Wallace has keenly advocated the supre- 
macy of cinchona as a cure for this affection of the eye. He thinks 
it has a specific influence over the disease ; recommends it both 
when the patient is weak and seems to demand tonics, and when 
he is in full health ; maintains the incurability of the disease by 
mercury ; and is decidedly of opinion, that there must exist some 
source of error in Mr Hewson's account of the cases cured by this 
medicine. ' When I commenced the use of bark in this disease,' 
says Mr Wallace, 'I did not venture to employ it when the in- 
flammatory symptoms were very severe, without preceding its 
administration by bleeding and purging. But latterly, whenever 
a case has presented itself, I have prescribed the bark alone, or 
simply with such medicines as were suited to the regulation of 
the bowels; and with the most decidedly good effects. Indeed, I 
have thought, that the abstraction of blood has, on some occa- 
sions, considerably retarded the cure ; yet cases may o<;cur in 
which bleeding and purging will be necessary." 

" I have not employed cinchona bark in powder, but the trials 
I have made of sulphate of quina have not led me to adopt any 
very high opinion of its efficacy in this disease. Some of the 
milder cases have yielded, in a great measure, to the combination 
of calomel and quina, such as Case 9. Case 5 was much bene- 
fitted by quina. In Case 10 it acted very slowly and imperfectly. 
On the whole, I feel indisposed to trust to this remedy ; and on 
this point I find my views corroborated by the experience of Dr 
Jacob. ' In two cases which I met with,' says he, ' after the in- 
flammation had subsided, and in which vision was as much im- 
paired as if no remedies had been adopted, bark, in powder, had 
been administered for ten days. I gave trial to the sulphate of 
quinine myself in four well-marked cases for eight days, but find- 
ing no relief, had recourse to mercury, which effected a cure in 
the usual time.' 

" I shall not unnecessarily extend this report, by commenting 
on the advantages to be derived from regulating the diet of the 
patient in this disease, and protecting him from cold ; on the uti- 



SEQUELJ5 OF THE DISEASE. 



147 



l)ty of warm fomentations, and anodyne frictions ; nor on the 
problematical effects of such internal remedies as tartar emetic, 
colchicum, or tm-pentine, which I have not tried." 

2. Glandular swellings. 

Glandular swellings have not occurred frequently among my 
convalescent patients, — not at least when under observation. I 
€an only find notices of enlargement of the superficial inguinal 
glands of the left side in one boy, — of the submaxillary glands in 
a man, and a girl, — of the right parotid and super-jacent lympha- 
tic glands, which went on to suppuration, in a man, — and ending, 
^is in the case of the old woman Janet Baillie, in an immense abscess. 

S. Boils. 

Boils have occurred in a few cases during convalescence, but 
never to a serious extent, except in one old woman in whom 
they considerably retarded convalescence. 

Pustular eruptions have appeared around the mouth in a few, 
but this has generally taken place immediately after, or simulta- 
neously with the crisis. 

4. Effusion into the knee-joint. 

Of this I have now seen three cases. All of those affected in 
this way had suffered, in recovering from the relapse, from pain 
in the knee^ — a very common occurrence. In two of the cases, I 
find no report of the treatment adopted, but I presume that it 
was similar to what I adopted the other day in the third case, in 
the Eoyal Infirmary: — viz., a blister dressed with iodine ointment, 
and the use of the hydriodate of potash internally. 

5. Swelled legs and ankles 

Are very common occurrences, especially, when the diet has 
not been sufficiently liberal, after the cessation of the febrile 
symptoms. Bandages, good food, and tonics generally remove 
the symptoms in a few days. 

6. Pain in the feet^ with, and without swelling, 

Has been complained of by several females. Mrs Finney had 
acute pain in the feet unattended by swelling. It came on 



148 



SEQUEL.E OF THE DISEASE. 



some days after recovery, and continued after she had ceased to 
be a patient, and was discharging laborious duties as a nurse in 
the male wards of the New Fever Hospital. Others had severe 
pain in the feet, with swelling of them and the ankles. 

7. Paralysis of the deltoid^ and oilier muscles 

Has been noticed in a few cases. In a female, aged 36, loss 
of power in both deltoids continued for about ten days, after res- 
toration to health in every other respect had taken place, 

8. Sloughing of j^arts 

Has been observed only twice. It existed to some extent in 
the cellular tissue in the neighbourhood of the parotid abscess in 
Janet Baillie. In Mrs M'Kay, aged 55, there was sloughing of 
the pudenda, and of the soft parts covering the sacrum; she had 
a very tedious convalescence. 



TREATMENT OF THE DISEASE. 



149 



CHAPTER V. 



TREATMENT OF THE DISEASE. 

From all that I have seen and read, of the epidemic fevers of 
our own and other climates, I am induced most cordially to join 
in opinion with those physicians, who regard these diseases as 
produced by certain poisons, the deleterious effects of which 
have an inherent tendency to pass off, after having caused a de- 
finite train of symptoms. It is this which explains the large 
proportion of recoveries in the young, and those of sound con- 
stitution, although the cases be treated by methods different, 
nay even opposite, in their nature. A knowledge of this fact 
ought to teach the practitioner, that his duty is to watch 
anxiously, and be ever ready ^ but nemr hasty^ to institute active 
interference, till special circumstances clearly indicate, that there 
is a necessity for it. " Our object must be," as Dr Thomas 
Watson remarks, " when the fever is once established, to conduct 
it to a favourable close — to ' obviate the tendency to death."* 
Upon this point, I agree most entirely with Pitcairn, who being 
asked, what he thought of a certain treatise on fevers, declared, 
* I do not like fever curers. You may guide a fever; you can- 
not cure it. What would you think of a pilot who attempted to 
quell a storm ? — either position is equally absurd. In the storm 
you steer the ship as well as you can, and in a fever, you can 
only employ patience and judicious measures to meet the diffi- 
culties of the case.**"^ 

Each individual case, as well as each epidemic, possesses cer- 
tain peculiarities, requiring different kinds of treatment; and the 
only general rule which can be safely followed by the practitioner, 

* Lectures on the Principles and Practice of Physic. By T. Watson, M.D. 
London, 1043 ; 2d volume, p. 710. 



150 



TREATMENT OF THE DISEASE. 



is that so correctly laid down by Cullen, and so urgently insisted 
on by Dr Alison, viz., " to olviate the tendency/ to death ; i. e. to 
oppose those of the series of morbid changes occurring during 
the disease, by which the fatal event in any individual case ap- 
pears likely to be brought about.''^ 

The great practical question, then, which we have to consider, 
in reference to the prevailing epidemic, is, in what manner does 
death take place, and how can the tendency to it be best obvi- 
ated ? 

At an early period of my experience, I became convinced, that 
there were three states most apt, either separately or conjointly, 
to cause death, and which, therefore, ought to be anxiously look- 
ed for, and, if possible, promptly corrected. They are 

1st, Co7igestion of the mucous memlrane of the stomach and intes- 
tines^ terminating in effusion of bloody and subsequent destruction of 
large potations of this tissue. 

2d, Congestion of one or more of the abdominal mscera, particu- 
larly of the liver and Mdneys^ disabling them from tJie performance 
of their secretive functions^ thereby causing bodies to circulate with 
the blood, which ought to be separated from it, and which bodies we 
know act as poisons ichen not so eliminated from, or when directly 
introduced into the circulation. 

od. Debility and sinking. 

4th, It will also he necessary to speak of the measures to be adopted 
to prevent or modify relapses. 

The best means by which to prevent these evils are the cautious 
but steady use of purgatives, the determination of blood to the sur- 
face and extremities, and in some cases, its abstraction. When the 
kidneys are not performing their functions, a small bleeding from 
the lumbar region by cupping, or even a dry cupping, in those 
in whom depletion would be hazardous, proves of signal benefit. 
Of course, when there is debility and a risk of sinking, cordials 
and stimulants must be administered ; and if, along %vith this, 

' Outlines of Pathology and Practice of Medicine. By W. P. Alison, M.D., &e. 
Edinburgh, 1843; p. 449. 



TREATMENT OF THE DISEASE. 



151 



which is no uncommon case, there be nausea or vomiting, they 
must be combined with sedatives. 

It has seemed proper to make these general statements, before 
speaking separately of the various therapeutic agents, which will 
now be done. 

a. Abstraction of Blood, 

This powerful method of interference for good or for evil, 
most naturally first claims our attention, as to it, have been 
ascribed numerous and great advantages. Several medical 
friends, who have visited the hospital, have urged me to prac- 
tise it, both generally and topically, from the success which 
they imagined had attended it in many cases. I have been 
told, for instance, and that very confidently, that patients bled 
in an early stage of the fever, had always a short and mild 
attack, seldom relapsed, or became yellow, and rarely sufifered, 
except to a very small extent, from muscular and articular 
pains. Though I certainly did not expect to reap these ad- 
vantages from the abstraction of blood, yet, observing that 
the fever was attended, in its commencement, by much arterial 
excitement and congestion, it appeared to me both reasonable 
and justifiable, to make some experiments upon the effects of 
venesection in suitable cases. In most, if not in all the in- 
stances, the headach was either relieved, or entirely removed 
for a short time, and the hard and frequent pulse was rendered 
softer and slower. These beneficial changes were often not 
effects, though sequences of the bleeding ; as was satisfactorily 
proved by the very same changes frequently occurring as sud- 
denly and unequivocally in patients in the same wards, and 
affected in the same way, xijlio were subjected to no treatment 
icJiatever. 

The blood was drawn from the patient when sitting up, 
and allowed to flow till he either expressed himself as suffer- 
ing less, or gave indications of approaching syncope. Few 
bore the loss of more than ten ounces, and several became 
affected with vertigo and faintness, after two or three only had 
flowed. Some persons, who whilst the blood was flowing, declared 
themselves quite relieved from the headach, within half an hour 
after the arm was bound up were found to be suffering just as 
much as ever. In fact, the severest headachs often ceased 



152 



TREATMENT OF THE DISEASE. 



spontaneously, and were always far more effectually and uni- 
formly relieved by the combined operation of a purgative, a pe- 
diluvium, and the constant application of cold to the head and 
back of the neck. 

In two of the cases referred to, delirium, intense general pains, 
and great debility, occurred in the relapse, and in one of them 
(Dallas) yellowness appeared, which was not the case in the 
first attack. Both of these persons were bled by Dr Heude, 
during my absence for some days in the country, so that I 
did not witness the first effects, which were favourable ; but when 
I returned, they had almost recovered from the first attack of 
the fever, and did not then seem to be worse than some others, 
who had been treated in the usual way. 

If ever there was a case in which the pulse, the general ap- 
pearance, youth, and robust strength of the patient, indicated 
the propriety of bleeding in this disease, it was in that of John 
Ritson, admitted in the fifth day of the fever. 

Case XXVI. — Summary. — Severe headacJi and articular pains. 
Relapse on the 14<t7i day. Quinine tried in large doses. 

John Ritson, a strong sailor, native of Sunderland, aged 19, 
of sanguine temperament, fair, florid, much sun-burnt, with light 
hair and eyes — who has been on board of ship, at Leith, for the 
last four weeks, since his return from Nova Scotia, was 

Admitted, 20th September, {fifth day?) He states, that he is ge^ 
nerally pretty sober, and has been quite so of late : his health 
has always been good ; he has had full, but easy employment, 
and the enjoyment of every comfort, since his arrival in port. 

On the morning of the 1 7th, he was seized with headach, and 
burning heat of skin, followed by sweating, after which, he had 
rigors. For the last two days, he has had pains in the joints, 
and last night, great uneasiness of the epigastrium, accompanied 
by vomiting, came on. He is not aware of having been exposed 
to contagion. 

His face is intensely flushed ; the expression is rather contract- 
ed, and slightly anxious ; the pulse is 108, and of good strength; 
the tongue is coated with a white creamy fur ; he has much 
thirst ; the last stool which he had was yesterday, from, medicine 



TREATMENT OF THE DISEASE. 



153 



previously taken : the skin is soft, and tolerably cool ; his sleep 
at night is little, and disturbed : the intellect is clear : he com- 
plains of severe headach, pains in the joints, and much feebleness 
in the limbs ; there is a good deal of pain at the epigastrium ; 
and increased dullness in the region of the spleen, which, how- 
ever, cannot be felt below the ribs. During the writing of this 
report, he has become very cold, and has at present (5 p.m.) some 
rigors. — Habeat statim enema purgans. — Habeat pil. colocynth. 
comp. ij node. — A lradatur capiUitium, et applicetur assidue aqua 
frigida toto capiti. 

21st Septemher^ {sixth day). The symptoms are much the 
same as they were yesterday, excepting that the headach is ra- 
ther increased, since a fit of vomiting which he had about mid- 
night ; after it, the pain in the epigastrium was considerably re- 
lieved : it still continues to a certain extent. The bowels were 
freely opened by the enema. The hair has been cut ; but cold water 
has not been applied, according to the prescription of yesterday. 
The pulse is 104, and of moderate strength. He has great thirst: 
the urine is abundant. — Gold water to he applied to the head ; an 
emetic of 12 grains of sulph. zinc, to he administered immediately; 
and the feet to he hathed in hot water at night, 

22d September, (seventh day). He is rather better than yester- 
day. The prescription was followed out ; the emetic operated 
freely, and there has also been considerable evacuation from the 
bowels; he slept well after the bathing of the feet. Pulse 104, of 
the same strength as yesterday; the thirst continues; the tongue 
is cleaning, and is moist. The countenance has lost a good deal of 
the intensity of the red flushing, and is beginning to assume the 
bronzed aspect. — Continue the cold to the head; to have no medi- 
cine of any kind. 

2Sd September, {eighth day). The headach is reHeved. The 
pulse is 70. The bowels are open ; and he is going on well in all 
respects. — Quiescat. 

24^th September, {ninth day). The pulse is 64, and small. The 
bronzing has become more characteristic. Some general abdo- 
minal pain is complained of; an excessively faint dark stripe ex- 
tends from the umbihcus to the pubes. There is much general 
pain over the whole body. — Habeat olei ricini %iss, statim. — Ha- 
beat haustiis cum solutionis muriatis morphias ass, hord somni. 

X 



154 



THEATxMENT OF THE DISEASE. 



25th Sepiemher, (tenth day). He had the draught, and slept 
well. The bowels are open. — Quiescat. 

28th Septeinher, (thirteenth day). On the 26th, he was ordered 
pills containing 3 grains of quinine, — to take six of them during 
each 24 hours. He appears to be quite well, makes no complaint, 
and is allowed to rise. He has taken 23 of the pills. 

2%th Septemle7% (fourteenth day). He is in every respect quite 
well, and has a great appetite. — To ham full diet, and a pint of 
ale. 

SOth September, (fifteenth day). About 10 a.m., he was seized 
with violent headach, and there has been some return of the ge- 
neral pains, and slight rigors. — To have loio diet. — Cold to the head, 
— Intermittantur pilulas quinince. 

1st October, (sixteenth day). The skin is very hot; he has 
sweated none since the relapse; the pulse is 108, and of moderate 
strength. There is some general uneasiness in the abdomen; it is 
not increased by the descent of the diaphragm, which goes down 
easily. The bowels are confined. — Continue cold to the head. — 
Habeat pulveris jalapas compositw "hiss, statim. 

2d October, (seventeenth day). He slept none last night, and 
has had no sweating ; he feels sick, and is worse than yesterday: 
the headach is increased; there are no general pains, but a feeling 
of debility; the pulse is 132, full, and not hard ; the skin is dry 
and hot, but soft ; the bowels were only once opened by the ja- 
lap : the tongue is white and moist ; he has much thirst. — 
Habeat enema purgans. — Habeat haust. c. tinct. hyoscyami Zi, hord 
somni. 

Sd October, (eighteenth day). He slept some in the first part of 
the night, but was awakened by a fit of rigors. The skin is soft, 
with some tendency to moisture; the pulse is 120, sharp, and 
tremulous at times. He has had a good deal of nausea, with 
some vomiting. There is a degree of double vision this forenoon. 
The countenance is pale, exhibiting an unequivocal bronzing. — 
Habeat pulv. opii, gr.ij, conserv. ros. q. s. ut ft. pil. ij. — Habeat j 
statim, et repetatur, hord somni. 

4th October, (nineteenth day). Sweated much immediately after 
the visit yesterday, and continued so till about 4 o'clock this 
morning, when his shirt was changed. Ho has had the two pills; 
but has slept none. The bowels were opened to-day. The tongue 



TREATMENT OF THE DISEASE. 



155 



is coated with a white fur. The pulse is 84, soft, and of good 
strength. 

October^ {twenty-first day). The bowels were opened by 
medicine. He is going on well, and has no complaint. 

^tli Octobe)\ {twenty-second day). He seems quite well, and is 
allowed to take exercise in the green for an hour. 

^th OGtoher^ {timnty-tliird day). Dismissed cured, and strong. 

In this instance, nature, assisted by the diligent application of 
cold water to the head, and hot water twice applied to the feet, 
and a drachm dose of the compound powder of jalap, accom- 
plished all that could have been desired from general or local 
depletion. 

It is supposed by some, that leeching is less objectionable than 
general bleeding ; but I think, that the contrary of this proposi- 
tion is often the truth. In opening a vein, and allowing the blood 
to flow, when the patient is sitting up, we have in the effect pro- 
duced at the time, an accurate index by which to regulate the 
quantity to be taken ; and then, it is almost always easy to 
arrest at pleasure the flow of blood from the brachial vein. 
With leeches, it is different ; and especially in the present epi- 
demic, where the tendency to hsemorrhage, and the difficulty 
of arresting it are so great, that I have several times seen alarm- 
ing depression caused by the oozing from one or twa leech bites, 
between the time wh^n they had been removed in the after- 
noon of one day, and the noon visit of the next. The special 
objection to leeching, is the danger of causing the loss of an 
uncertain quantity of blood. In the case of Mullans, already 
described, (page J 2), it is recorded, that the leech bite bled 
little ; but this was an unusual occurrence, and must be attri- 
buted to the diligent and free application of cold water, — means 
which, however, were not always found effectual in accomplishing 
this end. 

Subsequent to the occurrence of Ritson's case, a boy was cup- 
ped for pleuro-pneumonia. In the circumstances, the treatment 
seemed called for. a.nd had the desired effect of subduins: the in- 
flammation, but the recovery was, for/ a long time, most tedious 
and uncertain, notwithstanding the liberal exhibition of wine and 
porter. In a case which occurred previous to that of Ritson, in 



156 



TREATxMEXT OF THE DISEASE. 



which there was no secretion of urine, stupor, and delirium, a 
cupping in the lumbar region was resorted to, with very great 
benefit. 

In several cases of pulmonary inflammation, of various forms 
and degrees, I have seen all the symptoms disappear under the 
use of antimony and morphia combined ; or the liberal use of the 
morphia and ipecacuan lozenges. These remedies, when used 
along with fomentations, sinapisms, or blisters, are safe, and ge- 
nerally efficient substitutes for local bleeding, in thoracic com- 
plications. As the result of my experience, then, in this matter, 
I would say, that the cerebral, pulmonary, and abdominal com- 
plications, in which it is proper to extract blood, are extremely 
rare, and that, in very many such instances, it is a most hazar- 
dous practice. The statements which have already been made, 
sufficiently justify this opinion, so far as the cerebral and pul- 
monary symptoms are concerned; and with regard to the abdo- 
minal affections, this will be equally easy. 

In some of the most severe and threatening cases of abdomi- 
nal pain, and extreme tenderness on pressure, the patients have 
been well brought through, simply by the dihgent use of copi- 
ous warm poultices and fomentations. Enlarged and tender 
spleens have often done well with this simple treatment. I do 
not mean to say, that it would be proper in all such cases to ab- 
stain from abstracting blood; but am anxious to point out, how 
exceedingly valuable these remedies are, and how much safer it is 
in weak persons to rely on them, than take away any blood. 
Francis Kose, {vide p. 60), when far spent in strength, was seized 
with acute symptoms of enteritis and diarrhoea. A little morphia 
was added to the whisky which he was taking to sustain his 
feeble and fluttering pulse, and his abdomen was most assiduous- 
ly fomented. Contrary to all expectation, the symptoms abated, 
and recovery ensued. Depletion in any form would, I think, 
have killed him. 

In robust females, in whom the menstrual discharge has be- 
come suppressed, or in others, in whom any flux has been stopped 
by the fever, or in those of apoplectic tendency, the propriety 
of bleeding may be a legitimate question to entertain. It is one 
which I have more than once had difficulty in deciding for my- 
self, but I must say, that I have never had occasion to regret, that 



TREATMENT OF THE DISEASE. 



157 



almost always, it was ultimately resolved, not to bleed. It is, how- 
ever, one of those points regarding which it would be absurd to 
inculcate obedience to any routine directory. 

As to a full bleeding cutting short the fever, I have no results 
of experience to offer on either side. Granting that it were jus- 
tifiable to make this point the subject of experimental investiga- 
tion, it certainly would not be possible to do so, upon a sufficient- 
ly extensive scale to yield results of any value, in the Royal In- 
firmary or Fever Hospitals of Edinburgh, as the patients (ex- 
cepting the house officials) are, with a few exceptions, some 
days affected with the disease, before admission. 

h. Medicines wMcJi act on the Skin. — During the first fortnight, 
I was in the habit of giving the aqua acetatis ammonise, Dover's 
powder, James' powder, ipecacuan, antimony, &c. in various 
forms and doses, as sudorifics and diaphoretics; but as I saw, that 
those who got none of them sweated as much as those who did, 
they were altogether abandoned. The Dovers' and James"* 
powders were often found to be worse than useless, by exciting 
troublesome vomiting. Blisters and sinapisms were occasionally 
employed as general stimulants for the relief of vomiting, and as 
counter-irritants in chest affections. For the latter purpose, 
croton oil was also used. 

c. Application of heat and moisture to the skin. — Although of 
opinion, that all diaphoretic and sudorific drugs are of little ad- 
vantage, and that violent sudorific doses are injurious, I am yet of 
opinion, that I have very often seen the best possible results from 
other means employed for the purpose of diaphoresis and sweating, 
such as the wet blanket, the partial warm bath, and tepid spong- 
ing. The general warm-bath is apt to produce exhaustion. I 
had three young patients affected with ardent fever, and dry 
hacking cough, closely wrapped up in a blanket wrung out of hot 
water. Above this w^ere placed several dry blankets. They 
sweated most copiously from ten to fourteen hours, and were then 
removed to a dry bed, where they all sweated again so freely 
as to require to have their linens changed. They emerged from 
this sudorific regimen, perfectly free from fever, cough, and 
pains : but excessively weak and languid. A child of four years 



158 



TREATMENT OF THE DISEASE. 



old, when in the initial rigors of the relapse, was treated in t4i8 
same way with equal benefit. I was led to try this plan, from 
having recollected that Dalrymple, in the fever of Carthagena, in 
1 740, and J ackson subsequently in the yellow fever of the West 
Indies, had found that decided and immediate benefit resulted 
from rolling the patients in blankets wrung out of hot salt and 
water. Had the supply of bedding been adequate, this method 
would have been in general use. Sponging with hot and tepid 
water was very useful, and grateful to the patients; but the staff 
of nurses was not sufficient to have it tried satisfactorily to any 
great extent. Earthing the feet and legs in hot water, was found 
to be signally beneficial in allaying restlessness, and disposing to 
sleep. Hot poultices and fomentations, in all the abdominal com- 
plications, with or witliout headach, have been found of signal 
advantage. 

d. Ap2?lication of cold to the surface. — Cold water to the head 
was, in general, found to be quite sufficient to allay the headach, 
if diligently used. In a few instances, muriate of ammonia, and 
other evaporating lotions were used. The aspersion of the arms 
and chest with cold water, had the effect of calming several rest- 
less and irritable patients. Dr Heude became much more com- 
posed and easy, after the continued bathing of his arms in very 
cold water for some hours. 

When the skin is dry, and its temperature above the healthy 
standard, cold water may be safely applied, at least to a part of 
the surface'; and to the patient, this is always exceedingly grateful. 
The effect produced will best regulate the quantity to be used, the 
surface to be acted on, and the time during which the application 
is to last. Of course, when any chilling results, the cold affusion 
must be stopped. If the application of cold water is deemed safe, 
the wet sheet of the hydromaniacs is not to be despised. It was 
a favourite remedy of Bancroft in the yellow fever of Jamaica, 
long before cold w^ater became the watchword of a sect of igno- 
rant, gasconading empirics. It was more from want of an im- 
pression of its necessity, than an apprehension of its danger, that 
I never tried this plan. 

It would be wrong to leave this subject, without remarking, 
that unless the skin be very hot and dry, the cold affusion is 



TREATMENT OF THE DISEASE. 



159 



dangerous. A neglect of this precaution, and a persistence in 
its use, after the surface had become chill, has, we must remem- 
ber, in the hands of the younger Frank and others, caused the 
supervention of pneumonia. 

e. Warm drinks are found very beneficial alone, or as adju- 
vants, in disposing to sleep, when administered early in the night, 
as soon as quiet is established in the ward. 

f. Cold drinks must be used in moderation, as they are apt to 
excite vomiting and pain in the epigastrium. Cold water, flavour- 
ed with oat-meal, and decoction of barley, are, from motives of eco- 
nomy, what I have latterly restricted the patients to. Of course, 
in private practice, when the patients wished them, various agree- 
able drinks may be prescribed, such as lemonade, soda water, &c. 
I may here remark, that I often found hospital and other patients 
get more relief from thirst, by allowing some small crystals of 
citric acid to dissolve in the mouth, than from any other thing 
which they tried for the same purpose. 

g. Purgatives. — The steady and cautious use of purgatives forms 
a most important part of the treatment. The great aim in admi- 
nistering these medicines, in this and other fevers, should be to 
clear out the bowels fully, and if possible, daily, — at the same time, 
carefully avoiding such substances and doses as might cause gas- 
tro-intestinal irritation, or debility from catharsis. In the early 
days of the fever, in cases where there was no abdominal tender- 
ness, and a strong pulse, I have found the compound powder of 
jalap very suitable and safe. The compound colocynth pill, com- 
bined with the blue pill mass, was also often selected, and found 
appropriate in these circumstances. From five to six grains of 
calomel is a good purge. If there seems to be a risk of its being 
rejected, it answers very well to combine with this, a quarter, or 
half a grain of opium, a method which will also be found specially 
convenient with the bulky purgatives. The same object may be 
gained by administering, either a few minutes before, or along 
with the purgative, an ounce of the creasote mixture of the 
Edinburgh Pharmacopseia. The black draught of sulphate of 



160 



TREATMENT OF THE DISEASE. 



magnesia and senna was sometimes given to assist the operation 
of other purgatives. When, as was very frequently the case, 
flatulence existed along with constipation, the compound aloes 
and assafoetida pill was used with the best possible effects : as 
were likewise turpentine enemata. 

As the object which I had in view in administering purgatives, 
was frequently, not to produce a discharge of serum from the 
mucous membrane of the bowels, but simply to clear away the 
accumulating sordes and feces, castor-oil was the drug most com- 
monly selected, on account of its operation being generally mild 
and uniform. If the patient had a great repugnance to this 
medicine, and another, nearly as suitable, was asked, it was given, 
with a view to prevent the excitation of vomiting. 

The action of purgatives was often assisted by domestic ene- 
mata; and when there was nausea along with obstinate consti- 
pation, infusion of senna, turpentine, croton oil, and other ener- 
getic substances were injected into the rectum, the drug used 
being selected according to the necessities of the case. It was 
only when there was a tendency to coma, and in a few very ob- 
stinate cases of constipation, that the more violent purgatives 
were given by the mouth. 

Among the violent purgatives, I must not be considered as class- 
ing croton oil, as in spite of its activity, it does not, if given in a mo- 
derate dose, produce irritation. I have seen a patient, after hav- 
ing had eighteen stools from a dose of it, little, if at all exhausted, 
after the purging was over. I have heard Dr Christison and 
others make statements to the same effect. Given in doses of one, 
two, or three drops, I never saw it produce abdominal irritation 
or debility, when administered either in fever or other diseases. 
Its operation has the advantage of being rapid, and soon over. 
It seems sometimes to produce a sootliing effect, in addition to 
its moving the bowels. There is probably much truth in the 
opinion which Mr Harket expresses regarding it as a suitable 
purgative in yellow fever. " Its power," says he, " in allaying 
gastric irritabihty and general nervous excitement, as well as re- 
storing the circulation to the surface, and thus relieving the con- 
gestive state of the internal and deep-seated central vessels, is 
really extraordinary; and though I have seen it for the moment 



TREATMENT OF THE DISEASE. 161 

when first given, increase the irritabihty, yet after a little 
time, I have hardly ever seen it fail in producing the desired 
end;'^ 

h. Medicines which act on the Mdneys. — When the urine was par- 
ticularly scanty and scalding, and pain complained of in the loins, 
these symptoms have been considerably alleviated by administer- 
ing the nitrate of potash, the spirit of nitrous ether, and other 
diuretics. A powder, consisting of twenty grains of carbonate of 
soda, and ten of nitrate of potash, may be administered every 
two or three hours. Warm fomentations to the loins, cupping, 
&;c., act most admirably in exciting the kidneys to renewed se- 
cretion, it is to be presumed, by preventing or moderating the 
congestion of these organs. When certain alarming head symp- 
toms occurred, associated with suppression of urine, I have al- 
ways directed the treatment to the kidneys, rather than to the 
head, from a belief, that the urea, not being thrown off in the na- 
tural way, was acting as a poison. The cases, however, in which 
such a line of treatment is indicated, are very few in number. 

i. Medicines used to check the vomiting. — Pure opium, or this 
drug in some form, w^as usually selected — as it generally happen- 
ed, that there co- existed with the vomiting, other indications for 
the exhibition of it, or some of its preparations. A favourite pre- 
scription — for which I am indebted to the example of Dr Alison — 
is a drachm of the solution of the muriate of morphia in the form 
of clyster. Vomiting of the most urgent kind, when nothing 
is retained in the stomach, is sometimes checked, and most 
commonly moderated, by this means. No medieines answered 
the various ends for which they were given more effectually than 

^ It is remai'kable to see somewhat opposite opinions given by Christison and 
Pereira, regarding this purgative. The former says : " It is distinguished from other 
powerful purgatives, by occasioning much borborygmus, by its action commencing 
speedUy and ending soon, and by the cathartic effect, however brisk and exhausting 
at the time, being followed by comparatively little debility." Bispensatonj, p. 382. 
Pereira, on the other hand, remarks : " In comparing croton oil with other violently 
acrid purgatives, we find it distinguished by its speedy operation, the great depression 
of the vascular system, as well as the general feeling of debility which it produces, 
and by the uncertainty of its operation." Second edition, vol. ii. p. 1115. 

Y 



16*2 



TREATMENT OF THE DISEASE. 



opiates. When, from any cause, they were deemed improper, 
the creasote mixture, in often repeated ounce doses, was sub- 
stituted, — in general, with complete success. I never prescribed 
the hydrocyanic acid in the hospital, from fear of mistakes 
occurring through the ignorance of the nurses and patients. 
In some very obstinate cases of vomiting and hiccup, in which 
both the opium and creasote failed, timidity on this score was 
the only cause of its not being exhibited. In private practice, 
I have used it, in the vomiting of this fever, with signal benefit 
in two cases, where the patients had an extreme and prejudiced 
dislike, both to opium and creasote. Blisters and sinapisms to 
the epigastrium, w^ere often employed alone, or as adjuvants to 
check vomiting. They are very useful. 

Jq. Mercurials. — In this, as in most other fevers, the tolerance 
for mercury is very great. This remark, must, of course, be held 
as applying only to the pyrexial period ; I have several times 
had my patients accidentally salivated during the intermission, 
by two or three pills having been used as aperients, consisting of 
two and a-half grains of the compound colocynth, and an equal 
quantity of the blue pill masses. It was also uniformly observed, 
that when salivation was caused by mercury given during the 
fever, it occurred simultaneously with, and not as a precursor 
to, returning health. These facts, therefore, leave us in doubt 
as to the amount of benefit to be ascribed to the mercury. A 
large part of the success might probably depend upon the opium 
which was given in combination wdth the calomel ; and this, along 
with the necessary support of the strength by stimulants, would 
possibly, in all the cases referred to, have been sufficient to carry 
the patient safely through the fever, if such a termination were 
at all possible. As to whether advantage w^as derived from the 
mercury in the yellow and other highly congestive cases, each 
reader can judge for himself, from the cases reported in tliis 
memoir. 

It may somewhat assist in forming an opinion on this subject, 
to glance at the experience and statements of physicians regard- 
ing the use of mercury in some notable epidemics of yellow 
fever. 



TREATMENT OF THE DISEASE. 



163 



At one time, we find this drug in high repute as a remedy in 
yellow fever, and at another, declared to be worse than useless. 
In 1 793, Chisholm who employed it extensively in Grenada, was a 
strong advocate for salivation, styling mercury " the best aid in 
the treatment of yellow fever;" but his narrative of cases does not 
justify this estimate of its curative powers. He gave it from a be- 
lief that the liver was the chief seat of the disease. This physician 
held, that the more difficult it was to salivate, the more malig- 
nant was the fever; in some cases, he found that 2000 grains of 
calomel failed in producing any constitutional eflPect, whereas it 
was caused in others, by so small a quantity as ten grains ! This 
certainly leads us to conclude, that the cases in which the 
mercury produced a beneficial efi'ect, were in themselves mild. 
Clarke, Fergusson, and others, equally with Chisholm, advocate 
the mercurial system, as the most efficient in restoring the se- 
cretions, and exciting the capillaries. They state, that when- 
ever there is evidence of the mineral having affi^cted the con- 
stitution, the indications of amendment begin to appear. This, 
it need hardly be remarked, is hasty and inconclusive reason- 
ing. Many of the cases which seem to be benefited by the mer- 
cury, might have recovered spontaneously without it. Perhaps 
there would have been fewer advocates for salivation, if this 
simple view of the matter had more generally suggested itself to 
candid inquirers. 

Bancroft declares, " that after some experience, assisted by no 
ordinary portion of inquiry and information, he had not been able 
to discover that the salivators were more successful than the 
others, and if not more successful, their practice has certainly 
been hurtful, because in most of the persons who have recovered, 
the (perhaps useless) salivation retarded the convalescence, and 
produced very troublesome affections of the tongue, mouth, and 
throat, with other ill consequences, as is well known and acknow- 
ledged, even by its advocates.'' 

This remark of Bancroft is equally applicable to all the cases 
which I have salivated in the prevailing epidemic. 

Dr Hush, in his account of the yellow fever of Philadelphia, 
in 1794, says, "mercury seldom salivated, until the fever inter- 
mitted or declined. I saw several cases in which the salivation 



164 



TREATMENT OF THE DISEASE. 



came on during the intermission, and went off during its exa- 
cerbation, and many in which there was no salivation, until the 
morbid action had ceased altogether in the blood-vessels by 
the fever Dr David Grant, in his Essay on the yellow-fever 
of Jamaica, avers, and probably with perfect truth, that he "has 
seen more victims to the mercury, than to the fever.'' (P. 51.) 
Enough has been said to show the fallacies into which even can- 
did mercurialists are apt to be led, and that is the only object we 
had in view in introducing these historical details. 

Many upon reading my cases, might suppose that the mercury 
exhibited was an active agent in the cure, and I am anxious to 
state, that whether it be so or no, the evidence is not sufficient 
to decide the question, and is upon the whole rather against the 
belief that it was beneficial. 

In the yellow cases which I have had since this memoir went 
to press, mercury has never been used, except in one instance, I 
think, when calomel was administered for the sake of opening 
the bowels ; and the cases have gone on at least as well as formerly 
during the pyrexial stage, and convalescence has been more 
rapid, from there being no retardation of it from sore mouth. 

As the biliary secretion is excessive, and not diminished in the 
yellow patients, it seems absurd to give a medicine, which un- 
questionably acts as a direct stimulus on the liver. The more 
rational treatment is to counteract the already unduly active 
state of the organ, and if that cannot be done, to clear away the 
superabundant bile from the alimentary canal, by suitable eme- 
tics and purgatives ; and at the same time, take all other possible 
measures to prevent its causing undue irritation there. 

I. Remedies to relieve the muscular and arthritic "pains. — After a 
very extensive trial of colchicum, both in large and small doses, 
I have come to the conclusion, that any relief which the pa- 
tients experienced, could not be attributed to its operation. I 
have sometimes fancied, that the hydriodate of potass gave some 
ease; and in convalescence — during which the pains are most 
severe — it is unquestionably a very seasonable remedy, as it ge- 

1 Rush's Medical Inquiries and Observations, vol. iv. p. .94. 



TREATMENT OF THE DISEASE. 



165 



nerally increases the urinary secretion, and sharpens the appe- 
tite. When arthritic pain is combined with, or followed by, 
effusion, the hydriodate has been given with advantage, both in- 
ternally and externally. 

Returning strength generally banishes the pains ; and friction 
with the soap and opium liniment enables the patient better to 
endure them. 

Within the last few days, at the recommendation of Mr Flem- 
ing, I have tried the tincture of aconite as an external applica- 
tion; but some time must elapse before an opinion regarding its 
efficacy can be given. 

7)1. Tonics. — Tonic remedies are of much advantage during the 
intermission, and in convalescence. The particular substance to 
be selected must depend somewhat upon the circumstances of the 
case. I generally begin with casparia or cascarilla; and after a 
few days, prescribe one of the mineral acids in small doses, three 
times a-day, — or quinine, in the form of powder, pill, or potion, as 
may be most agreeable to the patient. Given simply as a tonic, 
from one to two grains of quinine twice or thrice a-day, have 
appeared to be a sufficient dose. In some patients, who have 
come in much exhausted from previous attacks, the saccharine 
carbonate of iron, and other chalybeates, have been found very 
serviceable. In persons known to be addicted to ardent spirits, 
quassia was the tonic often preferred; and it seemed to suit re- 
markably well. Port and sherry wines are the best tonics, but of 
course are too expensive to be used as common hospital remedies. 

n. Astringents. — Astringent remedies are required occasion- 
ally, as when diarrhoea, dysentery, bronchitis, &c., complicate 
the cases. The only astringents which I have had occasion to 
prescribe, have been the chalk mixture of the Edinburgh Phar- 
macopoeia, the acetate of lead, and opium, singly, or one of the 
former combined with the latter : — except in a few obstinate 
cases, in which the logwood was used. Of course various other 
astringent remedies might have been used with equal propriety. 
In two cases of very troublesome chronic bronchitis, the ace- 
tate of lead combined with squills, proved of remarkable ad- 



166 



TREATMENT OF THE DISEASE. 



vantage; — the formula used, was that recommended in certain 
cases of this kind by a recent writer, — I think by Professor 
Henderson, — viz., a pill consisting of four grains of the acetate 
of lead, and one of squills. In the cases referred to, one of 
these pills was taken six or eight times, at intervals of four 
hours; after this, they were used less frequently, so long as the 
symptoms continued. I regret that I have not made trial of 
the astringent powers of gallic acid in some of the cases of 
profuse menstruation, — a remedy which has of late been brought 
into considerable repute by Professor Simpson. 

0. Specific febrifuges. — No observations worthy of being record- 
ed, have been made with this class of remedies. The chlorinated 
solution of soda has been frequently prescribed, but nothing can 
be said of its therapeutic value; — the patients were not injured 
by it. 

The administration of large doses of neutral salts has been 
contemplated in several bad cases, but never, as yet, actually 
practised. Dr Stevens recommends this mode of treatment in 
yellow and other malignant fevers, from a belief that the black 
colour of the blood depends upon an excess of acid ; and he as 
well as others have spoken strongly in favour of its practical 
advantages.^ 

p. Diet. — The regulation of the diet, from the moment that the 
appetite begins to return, ought to be a matter of the most spe- 
cial attention. When there has been much abdominal congestion 
during the febrile period, accompanied by debility, bland, nourish- 
ing, but not over-stimulating, food is required. Weak beef-tea, 
as a drink, arrow-root with a little wine to dinner, and tea and 
bread, in the morning and evening,— have sometimes been or- 
dered in preference to the low diet of the hospital; but whenever 
the circumstances of the patient admitted of it, extra articles of 

1 The theory is ingenious, but much of the reasoning by which it is supported is 
unsound; and the statements made regarding its efficacy in the West Indies, are greatly 
though not intentionally exaggerated. Those who wish to understand the merits of 
this question, cannot do better than read the work of Dr Stevens on the blood, and 
a letter by Dr Hacket in the 1 7th vol. of the Medico-Chirurgical Review. 



TREATMENT OF THE DISEASE. 



167 



food were not employed, and the ordinary diets of the house were 
prescribed. The authorised diet tables are subjoined, that the 
reader may the better understand the prescriptions regarding 
diet, to be found in the reported cases. 



DIET TABLE OF THE EDINBURGH ROYAL INFIRMARY. 



Breakfast, 



Supper,. 



I. — LOW DIET. 

Bread, 3 oz. 

Tea, 4 pint. 

^ Bread,... 3 oz. 

Dinner, Panado, < Milk,.... 2 oz. 

( Sugar, ...^ oz. 

Bread, 3 oz. 

Tea, I pint. 

II. — RICE DIET. 

( Bread, 3 oz. 

Breakfast, < Coffee, i pint. 

( An Egg. 

Dinner J Beef- Tea, § pint. 

I Rice-Pudding. 

( Bread, 3 oz. 

" \ Tea, 4 Piiit- 

III.— STEAK DIET. 



Supper,. 





6 oz. 






Potatoes, 


16 oz. 


Beef Steak, 




Broth, 


1 pint. 




6 oz. 


Tea, 





Dinner,.,.... 

Supper, 



IV.— STEAK DIET WITH BREAD. 

The same as No. III. except that 6 oz. 
oi Bread are substituted at Dinner for Po- 
tatoes, and I of a pint of Beef-Tea for 
Broth. 



V.- 

Breakfast, I 
Dinner,.... 



■COMMON DIET. 

Bread, 6 oz. 

Coffee, 4 pint. 

J Potatoes, 16 oz. 

i Broth, 1 pint. 

c, ( Bread, 6 oz. 

S^^^^^' iTea,... ipint. 

VI.— COMMON DIET WITH BREAD. 
The same as No.V. except that 6 oz. of 
Bread are substituted at Dinner for Po- 
tatoes. 

VII.— FULL DIET. 



Dinner,. 







Butter-Milk, 










, 16 oz. 




3 oz. 


Broth, 


1 pint. 


Potatoes, 


16 oz. 


New Milk, 


....1 pint. 



Supper,. 



VIII.— FULL DIET WITH BREAD. 
The same as No. VII. except that Bread 
8 oz. is substituted for Potatoes and Bread 
at Dinner; and Bread^ 6 oz., for Potatoes 
at Supper. 

IX.— EXTRA DIET. 

Porridge, 2 pints. 

Butter- Milk, 1 pint. 

( Boiled Meat, 8 oz. 

DmNER, Potatoes, li lb 20 oz. 

' j Bread, 3 oz. 

( Broth, 1 pint. 

Potatoes, 1^ lb 20 oz. 

New Milk, f pint. 



Breakfast, 



'{ 



Supper 



' { 



1. Each Pint of Porridge to contain Three Ounces of Oatmeal, 

2. Each Pint of Broth to contain One Ounce of Barley, Three Quarters of an 
Ounce of Vegetables, and to be made with Butcher-Meat in the proportion of Two 
Ounces of Butcher-Meat to each Pint of Broth. 

3. In all the Diets, the weight is to be understood as applying to the food before 
being cooked. 

By authority of the Managers, 

(Signed) James Hope, Clerk to the Incorporation. 

Edinburgh, 2G^^ June 1843. 



168 



TREATMENT OF THE DISEASE. 



These different diets are upon the whole well adapted for all 
ordinary circumstances; perhaps the omission of porridge to 
breakfast, in the common diet, is unfortunate, as few of the pa- 
tients like to breakfast without it. The dinner pudding, again, 
in the rice diet, is so sweet as to disagree with very many. 

q. Treatment to prevent or modify relapses. — The result of many 
trials with sulphate of quinine in all doses, is— that it may often 
be made to modify and delay, but seldom to prevent relapses. 
Of late, I have trusted more to general tonic treatment, careful 
regulation of the diet, and good nursing, than to any special an- 
tiperiodic treatment. 

Having expressed this opinion of the sulphate of quinine, it 
may be well to quote one of the cases in which it seemed to 
prevent a relapse. 

Case XXVII. — Summary. — Crisis ly sweating on the night 
hetweeen the 1th and Sth days. — No relapse. Treatment^ qui- 
nine^ ^c. 

Robert Watson, Scotch, married, aged 47, a weaver from 
Paisley, of spare but strong make, having dark grey hair, light 
eyes, and a weather-beaten countenance, was 

Admitted^ 25th September, 1848, (fourth day.) He states, that 
he has been in Edinburgh only one day. Owing to want of em- 
ployment in his own trade during the last two years, he has been 
obliged to take any kind of work for which he was fit ; and lately 
he has been driving cattle. During these two years, he has been 
frequently pinched for food. He had fever about 25 years ago. 

He took ill on the 22d, with headach and pain in the eye-balls, 
shivering, and a feeling of weakness. These symptoms continued, 
and there was superadded entire loss of appetite. He ascribes 
the origin of his illness to cold and fatigue. 

His pulse is 96, of good strength ; the tongue is brown, but 
moist ; there is much thirst ; the bowels are confined ; the 
skin is hot, and dry ; there is no eruption ; he has severe head- 
ach ; the intellect is clear ; he has a bad taste in the mouth, and 
feels very much depressed. — Applicetur aqua frigida capiti. 



TREATMENT OF THE DISEASE. 



169 



26tk Septemher, {fifth dat/.) The headach is easier ; the other 
symptoms are much as yesterday. — Injiciatur enema purgans 
statim, 

'^Hth Septemher^ {sixth da^.) His bowels were opened by the 
enema; the pulse is 90, of good strength; the skin is hot and 
dry; he has a good deal of headach ; there is slight bronzing 
of the countenance. — Continue the cold applications to the head. 

2^th September^ {seventh day.) The headach is much relieved, 
but he complains of confusion of ideas; the pulse is 104 ; the 
tongue is parched and chapped; he has had several stools. He 
slept none during the night. — Haheat haustum c. solutionis mu- 
riatis morphice ^ss h. s. — Haheat mni ruhri 

2^th Septemher^ {eighth day?) He is much better to-day. He 
slept, but was unconscious of it, sweated profusely, and was 
greatly troubled with dreaming. The puke is 72, and stronger 
than yesterday ; the tongue is moister, but still chapped ; he has 
had two stools to-day. — To have a pint of ale instead of the wine, 

SO^A September^ {ninth day.) He is improving. 

l5^ Octoler^ {tenth day.) He slept last night without a draught, 
and is greatly improved. The tongue, skin, and pulse are na- 
tural ; the bowels are confined. — Haheat pulveris jalapm compos. 
Ziss, statim. 

%th Octoher^ {fifteenth day.) As he feels pretty strong, he is 
allowed to rise. He complains of slight pain in the shoulders. — 
R. sulphatis quinince ^^, acidi sulphurici diluti 3*, infusi gentianw 
^iv. Sumat unciam seoctd qudque hord. 

9th Octoher^ {eighteenth day.) He is quite well ; he finished 
the mixture this morning. — Continuatur mistura quinines. 

19th Octoher^ {twenty-ninth day.) He has been in perfect 
health since last report, and is to-day dismissed cured, having 
had no relapse. The quinine mixture has been continued till 
now, with the exception of the 12th, on which day it was omitted, 
not because it had caused, but lest it should produce headach. 



The relative expense of the treatment of different hospital 
physicians is very striking, and extraordinary. In a return to 
the Managers now before me, I find that the monthly expense of 
each bed varied, in difi'erent wards, during the months of Sep- 
tember and October last, from lis. to L9s. Id. This private 

z 



170 



TREATMENT OF THE DISEASE. 



official document to which I refer, — and which I have no right 
to quote except as regards myself, — states that my monthly 
average expense during that period, when I had never under 
84 beds, was at the rate of 12s. lOd. each. 

A very erroneous idea of the severity and duration of the 
disease may be entertained, by looking only at the long stay in 
hospital of many of the patients. The dismal desolation and po- 
verty of some of the poor families, made it often imperative to 
keep in patients long after they were better of the fever. An 
orphan boy, for instance, who lost both father and mother, and 
had no home to go to, could not at once be cast a-drift upon the 
town; and with young respectable females, without home or 
friends, the difficulty in deciding how to act was often extreme. 
Often have I known that heads of families, dismissed in good 
health, but too feeble to resume their employments, have gone 
back to their cheerless homes, only to pledge the few articles of 
furniture which they possessed, and thus at once get involved in 
difficulties, from which they never could extricate themselves. 

I cannot imagine any thing which would have a more powerful 
effect in repressing juvenile prostitution, theft, and kindred 
delinquencies, as well as in preventing the spread of cureless po- 
verty, and its constant companion, desolating disease — than a 
large and well managed Convalescent Hospital. Is there no in- 
fluential citizen in Edinburgh of sufficient energy to move the 
public in good earnest, in behalf of so noble an enterprise 1 



STATISTICS OP THE DISEASE. 



151 



CHAPTER VI. 



STATISTICS OF THE DISEASE. 

It was intended to have given tables showing some of the cir- 
cumstances of the patients, as to exposure to contagion, the crowd- 
ing into small rooms, and their comparative poverty or comfort; 
but the irksomeness of this labour causes them, at least in the 
mean time, to be delayed. It may, however, be stated, as the ge- 
neral impression left upon the mind by the inquiry, that poverty 
cannot be said to be the cause of the prevalence of the present 
fever, except in so far as by inducing general debility, it predis- 
poses to disease, and especially to any prevailing epidemic. The 
crowding of persons so predisposed into small and ill-ventilated 
apartments is, there can be no doubt, at once the main cause of 
the spread of the epidemic, and also of its confinement in a great 
measure to the habitations of the poor. 

The subjoined tables exhibit at a glance the statistics of the 
relapses, along with some other facts regarding the cases. In 
reference to the date of the relapse, it may be stated, that the 
late occurrence of it in many cases is supposed to be owing to 
the special treatment adopted. Some of the relapses were so 
extremely short and slight — especially those treated by anti- 
periodic remedies — that they would certainly have often been 
overlooked, had the cases not been placed under very strict 
observation. 

The determination to supply no facts from memory, is offered 
as some apology for so many blanks appearing in the subjoined 
tables. They exhibit a view of 203 cases, including all those 
which proved fatal. Unfortunately, there is no record of a large 
number of the mild cases. 



172 



STATISTICS OF THE DISEASE. 



03 o 



> ^ 



g « .3 



SI 



ri CO 

o a « 5' g 



p a; 



fan 



m « S 



1^ 



S 0? > ^ !h 



r' o oT _ 13 



S ^ > ^ !h 

I i g g-^? g3 



S3 - 



0) 

-t^ -^s -fi 



Q CO 



•I -2 5 1 i 



!72 



3 2 

si 



- fi 3 © 



§ ^ ^ 
res W 2 



C i-l © ^ 

I ^ § -2 g 



' © 92 



3 g^"- o S 



^>^©©5'^.-=52j'a^2>>§ 



o 



E3 

<t5 



© 

CO 



P 



3 

<! 



Q 



rH O 



a 

^ o-> 




^ 51) 

O 3 



5J 



- ^ I 

>> fcO 
^ ^ < 



3 

o 










Bai 






S 


© 


Wi 


Rol 



1-3 P5 



3 

QQ 
© 

i 

•-5 



STATISTICS OF THE DISEASE. 



173 



^ g ^ 

CU ^ 0) 

^ ^ 



53 <D 

^•3 J 



C5 

.2-5 

& o 



Ph ^ eS 



i § £ ^ 



CD 



o 2 



^2 -73 S3 
if a> o 



c3 a> f3 

CO C 
2 o 



O ^« 

«2 



03 O 

CC rj <D 

O 'm «2 

0 S 



O 

ei I- 



-I' 



0 



h3 0 >- ^ 



o <v ^'^ 

« 3 CM 

rrt *S ''3 PhTS 

> ce (u 






















CM 


iOCN— ^COC0(^^^J^CO 
CI (M CO CO CO i-< 










CO 




(NC5<J5tO«OOCOCO 

.— I(M(M.— li--r-Hi-H(N 


CI 


CO 


<£> 


INOt KIK 


August 




S 


Septem, 






CO 
CQ 


CO 


00 


cococicjooeoco 








j Aug 














-ired 






Died 
Cured 

Died 
Cured 

35 
35 



































■5 "B 



3 



bfl tUO bJD R 
3 3 p 



fcJD 
<1 



CO >-H CO CO »t5 
^ CO ^ ^ r- 

05 CO CO CO 

§D >> §0 R S) R R >> 
3 "3 3 3 3 



to 
.3 



3 « o 

oT o --T o ' 
„ 2 > '53 .a 5 



1-5 



S S 



^5 « 

Cj 0) ^ 



-3 



a> • S 0} ^ o 



: I 
1 S 

3 



174 



STATISTICS OF THE DISEASE. 



Oh 



— ' o 

II 



.2 13 



C3 




S 

<u © 

o o 

I— c 00 



Period 
under 
Observation 


COr-iCOi-Ht>.<M-r}<Tj<Ot^i-Hto-^— <Oi O OOOO O CO Ol (M r-H 

.-.iOr-l r-((M^rH.-HF-lCO(MM^C<l r-( CO(Mr-lf-lC<l COCO 


Date of Dis- 
missal. 


«5005COr-icocOOO'«J<r-HiCOCiCOt^ Ci ClCSCatM (M CO ^ CO 
-"^CMl-lr-l r-H<N(M(M<M cq^^^ ^ 

s 1 a -s a 1 a a I a © 

M O 02 <3 c/2 O c/2 m O m O 


Date of Ad. 
mission. 


a 


Result. 




No. of 
Re- 
lapses 


o 


Day of Disease 
on which 
Relapsed. 


13th 

lith 

16 th 

18 th 

12th 
13th 

14th 
18th 


Date of relapse. 


August 27 
Not known 
August 28 

None in hospital 
Septem. 7 
Not known 
None in hospital 
None in hospital 
None in hospital 
None in hospital 
Not known 
Septem. 10 
None in hospital 
Not known 

Septem. 8 
No relapse 
None in hospital 
do. 

Septem. 14 

None 

j Admitted \ 
< during > 
( relapse ) 
Septem. 17 


Date of 
Seizure. 


August 15 
„ 17 
„ 18 
Not known 
August 24 
„ 2.3 
„ 21 
„ 22 
„ 23 
„ 24 
„ 23 
23 
„ 24 
„ 24 
Not known 
( admitt. 1 
I during \ 
( relapse ) 
August 28 
„ 27 
„ 31 
„ 31 

Septem. 2 

Not known 

Septem. 4 

„ 2 


flj 

bo 
•S3 


oooooeoeococ50(M»CffOt— (N coeocoi^5 C<1 ->* CO t>. 
--iCO(N^-^(Me>0.-HCOC0(N ^(NCO (M COeO(MC>Or-H lO (N .-H^ 


Name. 


James O'Connor, . . 

A. Campbell, .... 
Angus Cameron, . . 
Peter Quin, .... 
K. M'Kenzie, . . . 

H. Perfect, 

H. Collins, 

H. Coyle, 

B. M'Peak, .... 

D. White, 

John Munon, .... 
Robert Eraser, . . . 

John Johnstone, . . 

John Paterson, . . 
James Smith, .... 
William Watson, . . 

N. Adams, 

J. Small, 

M. Golden , 

J. Aitken, 

Patrick Fagan, . . . 



STATISTICS OF THE DISEASE. 



175 



a c3 

a 

a> o 



a s 



50 

•1 



3 



^ B u 

o . " 



0 « 

03 O 

^ s 



o ST 



.9 



CO 0) o a> 
bo W) 

Ph Ph 



.52 Ph 

1^ «§ 



.2 



S -5 
m O 



(M !>. 05 05 "5 

a s 

1 1 ... . 

CO O 



i 

Ph 

a> 
m 



(M (N (M (N CO 




*0 05iO'^'0*OJC^(Mu:)^-^ 



H +3 -tJ -fJ -tJ 



JO CO M< 



lo ec 

(M —1 (M C<1 <M 



a 



0) 



R O 



. -4-9 

O CO 



R o o © 

iz; o Q 



I CO I ^ 2 

CO <i CO 



pq 



CO 



-pf§ 

o 

pi; a 



^ a 



.3 



. p^ 
. a 

o 



il 



P5 g' 



176 



STATISTICS OF THE DISEASE. 



§ § 

(11 +r 



C5 








»f3 


eo 






CO 




o 




(U (D 


CD 




be 


!» o 


be fco 


Ml 


be 




.2 «^ 


173 d 

P-i Ph 




ex, 


Vide 




Vide 


Vide 





Period 
under 
Observation 


030i-H (M'-i !>. eCCOi-H 


05 • • 

: CO : : 


Date of Dis- 
missal. 


October 9 

„ 18 

„ 15 

Novem. 10 
October 26 
Novem. 13 

Novem. 21 


• o • • 


Date of Ad- 
mission. 


t-< 

CD 

R RRR R RRRRRR 

O 


—t CO ^ 00 


Result. 


.11 R r1 R 1 RRRRRR 

fid fid 


R 11 R 

fid 


No. of 

re- 
lapses 






Day of Disease 
on which 
Relapsed. 


13 th 
14th 

Not known 

15th 
15th 
14th 
21st 
Not known 


18th 
16th 
13th 


Date of Relapse. 


None 
Oet. 12 

None in hospital 

Oct. ] 3 

None 

Oct. 9 

„ 20 

„ 17 

„ 20 
Not known 
None in hospital 

Not known 

1st on Oct. 23 
Oct. 23 

„ 26 


Date of 
Seizure. 


(M CO eO <N (M .tS a ^(M CO fl r-, 


<u 

60 


C<JeO(MiOC<Jl>- (N OCOOCO^D(N C0C5O 
eOCNCNCOTt^iO i-l COr-H(Mr— ,-(CM r-H ^(NCN 



9 o 



flJ O OS 

^« Q 



.•^is 5 • bJ 

9 §*=^;^ u 



o 



§1^ 



w 5> a3 

Q> d 0) 

III 

►-5 C« >-5 



STATISTICS OF THE DISEASE. 



177 



^ .a 



CO o 



Up g<| o 
S3 (M 





O (u oj 



2-^ 

O m 
P 



1o S S 

< U2 O < 



< 



Is 



13 



6- 

CO 



to CI 


02 


CO 


^ s 

C! ri^i 

S o 


fone in he 


;3 

bX) 


<I 12; 


<1 




C5 r-H 

.-1 (M 



>-5 




;4 ^ 



«.a ?^ 



o 

bD 






1 


Gre, 


ardi 


ci 

0) 


to 










>-5 


w 

1-3 


H 





2 A 



178 



STATISTICS OF THE DISEASE. 



o 03 CO 

5? «^ 9 

-So-" 
53 ^ o 

n=! R fl 



S ^ .2 &4 !3 



* I 



S J 

- f5 ^ >ii 

.2 O f3 S 

M 



Q 

I 

d 
• .2 



2 ^ 



.9 S 



Oh 

CO 

a I ^ 

2 S o 



'T3 « 



o 

.a .a 



3 



-2 t; 



1| 



O ^ (H 



S3 o 



13 >h 43 
O OJ nj 

O 



1 a 

=3 O 3 



^ ^ ^ 



2 a 



O c« 



o o 



O 



A A 

-t-s h3 
.— I CO <M 



to 0 














CO 


o 


O -ts O 


o 








.a 




o 




o 






o 


fon 


<1 



i 



<1 




n 
o 

















J? s >^ 
-< d d 



<j ^' <i p4 4 ^ H CO 



^ Sac 



1^ 
3 O 



STATISTICS OF THE DISEASE. 



179 




O O 







CO 


CO CM —1 


(M 




(M r-f CO 


CO 


CO <N 


CO 






O iJ^ 05 
CO (M «-H 


CO 

(N 




O AO iO O 
CO r-H CO 


(M 


CO 


Septem. 




October 


1 . . 

a> 

CO 






October 
Septem. 


October 


Septem. 


o 

CO 


o 

CO 


CO 


r-H r-< Cq 


(M 




^ CO CO CO 


CO 










S 

(U 
CO 










R R 



03 

r-H (N 

O 



■5 -B 

CO CO 




CO 



fl CO 
^ (M 

§ B 

^ S R R 
CO 



CO O I 
CI CO g 



O S3 

12; <J 



W '•W U-'J 

CO 

CO 



a 

-2 

CO 



a a 

si a 



c3 a 



^ d oj a pi: 
^ W d Q w w 



180 



STATISTICS OF THE DISEASE. 




■i3 'a 
^ o 

IS 



.S .S J .&_g S :S 

^ f-i is 'S ^ 
^ ^ I ^ 




c3 O 



0^ — * 



«^ S 
O 



■73 



s s a 

(D O o 



S 

c« O 



i8 



i 

Oh 



■t>- 05 05 Ol Oi 



X-'. CO CO 



(M .-I 



>.§p; 
Q 



" 'o 



^ (TCI 1/^ 



o 



(M O C5 

^ (N CO <M (M 

is 



s 

Ph 

0) 



a 

s 



It 



h3 d »-5 c/i f4 H W CO 



a 


a ^ 

2 

CO o 




IS 


Grahai 


Mathe 
. Wind 


1 


Pirrie, 
Hamil 






^* 


1-5* W5 



STATISTICS OF THE DISEASE. 



181 



•r^ ^ 'TS 



a 



•a 

o 



12 

.I* 



^ ^ 



Oh 



...... r 

O o 

;zi o 



to O C5 J>. (N CO 



> 

o 



.i . 

o 



-2 



Q O 



CO 



^^^^^^^^^ 



£ So £ cS oi 
^ ,_, ^ ^ ^ ^ 



^ ^ ,c! 

^ 4^ ^ 

CI CO lO CO 



05 CO 



CO 



o 



fl Ol CO 1^ CO 

g (N (M 

O fci 

a o 



lO W C5 CO 

. . . . .I ^ 

o o o 

o g;^ 
o 



CO a CO M< CO 



§ s ^ 

^ c« O 



a C5 
o "S 

^ o 



CO CO CO t-^ CO 



r-l r-( C5 (M (M (N (M 



05 CI 

a § a 



crico»ococ?5co Sx>.co>— <o— ii-hcoc<j 
<M (M C-l CM (M (M ^ I— I CO <N 



12; CO o 



a s 



a s 

-« O -MO 

CO O CO O 



53 ^ £ 



^ ^ c-g S.2^ . a 

^•-a^ f^^pS fl-^ i^H-i c 



s :^ pl; d ^ H s K H w ;^ d s w »i5 k w :^ ^ s s :^ si g s ^' 



182 



STATISTICS OF THE DISEASE. 



q 



% s 

Q 



o .S 

+3 fl 5 O ^ 

I :! s s ^ 

HH O O 



0-5 



a I 



OS a 



oj a 



• "5 CM 




Oh 
CO 



CO ^ 

^* IS 



0> (M 
CO CO O 



a ^ a 
OHO 



CO 

!=! rS T^ 

a ^ ^ 

•^ « a 

° S « S 

tn S a> ? 



>> «« a 
1-5 (u -a o 



(0 X5 



LIBRARY OF CONGRESS 



0 021 623 786 9 



^^^^ 

■5" 



